Pediatric Nursing Quiz 1

Dietary history

-24 hour recall -Food frequency questionnaire -> daily, weekly, or monthly -Food diary -> 3-7 days

Types of families

-A client's family is who the client thinks/says is their family Traditional (Nuclear families) -Headed by two parents who view painting as a priority and are not suffering from very stressful situations (e..g, poverty, illness, substance abuse) Non-traditional -Single-parent -Blended -> children are brought from a previous relationship into a new one -Adoptive -Multigenerational (3 or more generations living together) -Same-sex -Communal -> living together but not related High risk -Marital conflict/divorce -Adolescent parenting -Violence -Substance abuse -Special needs children -> often suffer financially, relationships with other children may worsen

Maintaining a safe place for the child

-A designated safe area can enhance a child's sense of security -Procedures that cause discomfort or anxiety should be done in the treatment room rather than the child's room -The playroom should be for playing, not treatments and medication

Croup

-A group of conditions characterized by INSPIRATORY STRIDOR, harsh (brassy) cough, hoarseness, and varying degrees of respiratory distress -Usually begins at NIGHT and may be preceded by several days of symptoms of upper respiratory tract infection. -Other manifestations include: >Sudden onset of a harsh, barky cough >Sore throat >Hoarseness >Inspiratory stridor >Use of accessory muscles >Frightened appearance >Agitation >Cyanosis The goal of treatment is to MAINTAIN A PATENT AIRWAY -Children with acute spasmodic croup can usually be cared for at home. Taking the child out into the cool, humid night air may relieve mucosal swelling. -For mild croup, oral dexamethasone decreases airway inflammation and reduces the necessity for hospitalization in many children. -Children with laryngotracheobronchitis (more severe croup) are more often hospitalized. Racemic epinephrine nebulized with O2 can be given to decrease laryngeal edema and bronchospasm. -Steeple sign shown on x-ray.

Barriers to immunization

-Appointment-only clinics -Excessively long wait periods -Inconvenient scheduling -Inaccessible clinic sites -The need for formal referral from a primary healthcare provider -Language and cultural barriers -Cost -Parental misconceptions -Inaccurate record keeping by parents and healthcare workers -Reluctance of health care workers to give more than two vaccines during the same visit -Lack of public awareness of the need for immunizations

Parenting styles

-Authoritarian -Authoritative -Permissive

Authoritative Parenting style

-BEST parenting style -Parents show respect for opinions of children -The house has rules, the parents permit discussion if the children do not understand or agree with the rules -Some negotiation may take place although the parents are still in charge Effect on child -High self-esteem -Independent -Inquisitive -Happy -Assertive -Highly interactive

The Ill Child's Parents

-Child's illness can create a situational crisis -Parents become very protective and vigilant to ensure optimal care for their child -Parents can help with emotional support, distraction, and returning child to normal routine -Parents feel unable to participate in care and decision making and they feel like they have insufficient information -> allow parents to be a part of care and decision making, teach parents about treatments and child's response to treatment Parents may feel: -Guilty -Denial -Anger -Depression -Exhausted ->Nurse may encourage parents to express feelings, active listening, assistance with processing feelings, referral for counseling -Remember the needs of the FATHER -ALL caregivers need recognition, support and education

Characteristics of Healthy families

-Communicate openly -Flexible roles -Agreement on basic principles of parenting -Adaptable -Volunteered assistance to each other -Spend time together -Seeks support from each other when needed -Transmission of cultural values and expectations to children

Assessment of development

-Data must be gathered from multiple sources -Developmental surveillance which includes a combination of eliciting parent concerns, assessing for risks, direct observation at every visit during infancy and early childhood -By watching a child during normal daily activities as well as problem-solving skills, communication patterns, interaction skills, and emotional responses can yield valuable information regarding a child's level of development -Standardized assessment tools should be sensitive (accurately identifies developmental problems) and specific (accurately identifies those who do not have developmental issues) -Parents want to know how their child measures up to the others. Developmental assessment tends to get rid of fears -The most important reason for assessment is to discover abnormal development early so that early interventions may take place

Otitis media

-Ear ache, pulling at ears -Yellowish green, purulent, and foul smelling drainage -Irritability, sleep disturbances, persistent crying in infants, fever, vomiting, anorexia, and diarrhea. -Dont treat with antibiotics right away -> wait 2-3 days (for acute ear infection) -> There must be an accurate diagnosis before treatment decisions are made. -Symptomatic treatment and observation for 48 to 72 hours after diagnosis as an alternative to Antibiotics -> -Pain relief -> increased fluids, tylenol, motrin, avoid loud noises Reassessment and treatment initiation for children with positive AOM (acute otitis media)after the observation period. For OME (Otitis media with effusion) that persists for more than 3 months and is associated with hearing loss -> myringotomy (surgical incision into the eardrum, to relieve pressure or drain fluid) with insertion of tympanostomy tubes may be performed. This helps any drainage in the ears to drain out and the tubes spontaneously fall out in 6-12 months -> tubes create a portal into the ear -> INCREASED risk for infection -> Obtain specific guidelines from PCP about getting tubes wet

Childrens responses to illness

-Fear of the unknown -Separation anxiety -Fear of pain or mutilation -Loss of control -Anger -Guilt -Regression

Laryngomalacia (Congenital laryngeal stridor)

-Flaccidity of the epiglottis and supraglottic aperture and weakness of the airway walls -> most common cause of INSPIRATORY STRIDOR in the neonatal period -May be caused by immature neuromuscular development in the airway -Noisy, crowing inspiratory respiratory sounds (stridor) are present, with or without retractions -Symptoms INCREASE when the infant is SUPINE or when they are CRYING -> HYPEREXTEND THE NECK to decrease obstruction and improve stridor Symptoms usually resolve without treatment by age 18 to 24 months -Nurse observes for stridor, retractions, and dyspnea and notes any signs of respiratory distress ->Assess respiratory status and document every 2 HOURS -Observe infant for any feeding difficulties and appropriate growth and developmental patterns -Teach family signs of respiratory distress -Teach family that smaller, more frequent feedings with smaller nipples on bottles are sometimes better tolerated by infants with respiratory difficulties

Post-op Tonsillectomy

-Immediately after surgery, the child should be assessed for bleeding and ability to swallow secretions. If bleeding occurs -> child is returned to surgery for cauterization -> NO RED DRINKS -> may be confused for blood -Suction equipment should be available, but do not suction unless there is airway obstruction (suction may pull out sutures) -When visually assessing site for clots or bleeding, use a flashlight for illumination and AVOID using a tongue depressor if at all possible -Vital signs need to be monitored frequently until discharge. -Assess child for bleeding -> frequent swallowing, restlessness, fast thready pulse, or vomiting bright red blood -> if bleeding occurs -> child in side-lying and call PCP -The child should be placed in a prone or side-lying position to facilitate drainage. -Provide clear, cool liquids when the child is fully awake. NO STRAWS post-op, it can pull out the sutures. -Day 10 is the biggest risk for hemorrhage because the scab in the child's throat should be coming off around this time -> Teach parents to observe for an upset stomach, excessive swallowing, painful throat, coughing up/vomiting blood for the 24 hours after discharge and again in 7-10 days -> CALL PCP -Vomiting old blood (coffee ground emesis) is common -> antiemetics to prevent pain from vomiting -> if vomiting -> child is NPO for 30 minutes -> then resume clear liquids -Provide clear cool liquids (AVOID carbonated, citrus, milk product, hot or cold liquids because they may irritate the throat)

Bronchiolitis (RSV)

-Inflammation of the bronchioles usually caused by RSV (Respiratory syncytial virus) -Mostly found in infants under 1 yr old -RSV is a causative agent in over half of cases. RSV can live on skin or paper for up to 1 hour and on cribs and other nonporous surfaces for up to 6 hours. Although it is not airborne, it is highly communicable. It is usually transferred by inadequately washed hands. -Children are on CONTACT PRECAUTIONS -SMALL risk for acquiring asthma Manifestations -Usually preceded by a mild upper respiratory infection -Serous nasal drainage -Sneezing -Low-grade fever -Anorexia Followed by -Onset of acute respiratory distress -> Tachypnea (60-80 breaths per minute), Tachycardia (>140 BPM), wheezing, crackles, or ronchi -Intercostal and subcostal retractions WITH OR WITHOUT nasal flaring -Cyanosis -Difficult feeding due to incraesed respirations interfering with sucking and swallowing -Possible high fever (up to 105.8 F [41 C]) Therapeutic management -Mild -> treated at home with fluids, humidification, and rest -Respiratory distress -> hospitalized -Cool humidified O2 is delivered is sat goes below 90% on room air to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea -Inhalation of hypertonic (3%) normal saline solution may improve respiratory status -Position the infant with HOB at 30 to 45 degrees and the neck should be slightly extended to maintain an open airway and decrease pressure on the diaphragm -Antibiotics are NOT GIVEN unless there is a secondary bacterial infection -RSV prevention is very important (IM Synagis) monthly throughout RSV season

Allergic Rhinitis

-Inflammatory disorder of the nasal mucosa that is usually seasonal, recurrent, and triggered by specific allergens -Classic symptoms of allergic rhinitis are clear -> rhinorrhea with itching of the nose, eyes, ears, and palate and sudden intense (paroxysmal) sneezing not associated with an upper respiratory infection -Allergic salute -> upward rubbing of the nose with palm -Treatment is to eliminate the allergen from the child's environment -Antihistamines and corticosteroids are also effective

Nursing Responsibility in Administering Vaccines

-Know the recommended immunization schedule -Acquire up-to date information -Assess the family's beliefs and values and educate families on the rationale, risks and side effects, and the risks of non immunization -Take a careful history to identify any contraindications and report to PCP -> educate family on contraindications -Make sure to check which vaccines should NOT be mixed -Administer according to manufacturer's recommended sites -Hand hygiene before administration and between children -Review with parents the potential side effects and signs of severe reactions and when to call the PCP -Tell parents that they may administer age-appropriate doses of acetaminophen every 6 hours for 24 hours for discomfort related to the vaccine -For painful, red injection sites, instruct parents to apply a cold compress for the first 24 hours; then use warm OR cold compresses for as long as needed -Give multiple administrations in DIFFERENT SITES and record those sites in the medical record -Document parental consent, type of vaccine, date of admission, manufacturer and lot number, expiration date, administration site, any data pertinent to risks and side effects, and the signature and title of the person administering the immunization in medical record

Factors Influencing Growth and development

-Mainly influenced by genetics -Physical and psychosocial environment (e.g., prenatal exposures, poverty, imported toys with leaded paint) >Immature tissues -> INCREASED risk for injury >High intake relation to body mass -> higher concentration of ingested toxins >More rapid respirations -> INCREASED inhalation of air pollutants >Larger body surface area -> increased absorption through the skin >Increased risk of hand-to-mouth transfer of hazardous materials >DECREASED ability to metabolize toxins >Environmental toxins form breast milk -> Nurses can assist with anticipatory guidance on how to avoid the most common sources of environmental exposure -Culture -Nutrition >Children need more nutritious food in proportion size than adults do -> appropriate portion sizes must be provided >Major nutritional factors of concern: *inappropriate food advertising *decreased access to affordable foods *availability of unhealthy sweetened drinks *lack of breastfeeding support -Health status >Malabsorptive disorders >Respiratory illness >Heart defects >Metabolic diseases -Family -Parental attitudes based on: >Education >Childhood experiences >Financial pressures >Marital status >Available support systems >Children raised in an enriching environment may develop faster than those without (must be provided when the CHILD IS READY to learn)

CF (Cystic Fibrosis)

-Most common lethal genetic disease in whites -Chronic multisystem disorder affecting the exocrine glands of the bronchioles, reproductive system, small intestine, and pancreatic and bile ducts -Defective chloride channel in epithelial cells -The mucous produced by the exocrine glands is abnormally thick, causing OBSTRUCTION of the small passageways of these organs -INCURABLE (survival rate is 40 years)

Brazelow's tape

-Offers approximate Kgs in weight based on height of child -Offers doses of drugs, calculations, and equipment needed for child to minimize time between incident and intervention

Permissive parenting style

-Parents have little or no control over the child -Inconsistent and unclear rules -Limits are NOT set -Discipline is inconsistent -Role reversal -> the child becomes more like the parent and the parents become more like the child of the relationship

Factors affecting the childs response to hospitilization

-Perception of events -Cognitive development -arental response -Preparation -> Honesty and use of age appropriate terminology is imperative -Previous illness or hospitalization -Coping skills of child AND family -> Breathing, distraction, and imagery -Psychological benefits of hospitalization -> improved coping -> Increased self esteem >New information learned in the healthcare setting

Pre-op tonsilectomy

-Reassure child that talking will not be affected after the procedure -Teach that drinking fluids after surgery is important even though throat will be sore -> hydration is very important -Teach family about post op pain assessment and appropriate analgesia administration (non aspirin analgesics such as acetaminophen/ibuprofen) (possible ice collar) -> under medication can interfere with optimal recovery

Authoritarian Parenting style

-Rules from parents -Obedience and acceptance of family beliefs and principles without question from the child is expected -Give and take is discouraged Effect on child -Shy and withdrawn due to lack of self-confidence -If parents are affectionate -> sensitive, submissive, honest, and dependable child -If parents withhold affection -> rebellious, antisocial child

Pediatric differences in the respiratory system

-SMALLER lower airways and undeveloped supporting cartilage -> INCREASED risk for obstruction by mucus, edema, and foreign bodies -> also, INCREASED risk for aspiration -Lung size is proportionate to body height -> lung volumes and capacities do NOT vary from age to age -Infants are NOSE BREATHERS, they have difficulty breathing through the mouth -> nasal congestion makes breathing difficult -> saline and bulb plunger to remove nasal occlusion -> neonates can EASILY enter RESPIRATORY DISTRESS -> Epiglottis and palate are pulled apart during rapid growth allowing mouth breathing after about 2-6 months -Retractions are more common in the infant -The diaphragm is the neonate's major respiratory muscle -Brief periods of apnea are common (10-15 seconds) in the neonate -Respiratory pattern may be irregular -Normal child's respiratory rate is HIGHER than adults -INCREASED metabolic rate increases oxygen needs -Lung growth continues into adolescent years -Eustachian tubes (canal that connects the middle ear to the nasopharynx) are relatively horizontal -> INCREASED RISK for bacteria entering the middle ear -Tracheal size triples by adulthood -Tonsillar tissue is usually ENLARGED in early school-age children -Infants and children use abdominal muscles to inhale until 6 yr -The child's flexible larynx is more flexible to spasm

Conflict in the family setting

-Should not be viewed as bad or disruptive -Conflict can produce growth and improve family functioning if the outcome is resolution as opposed to continued conflict To resolve conflict -Open communication -Accurate perception of the conflict -Constructive efforts from the family such as seeing the conflict from another's point of view, considering alternate solutions, and compromise

The Ill Child's Siblings

-Siblings may experience jealousy, insecurity, resentment, confusion, and anxiety -Siblings often have a hard time understanding why their ill brother/sister is getting all of the attention -Excessive worrying about ill sibling is common -> address the siblings feelings of guilt (if continued, refer to a counselor) -Take time provide appropriate information to the sibling

O2 monitoring for the little ones

-Special leads that wrap around fingers, toes, arms or legs -Make sure the skin is clean and dry -No nail polish -Check hospital policy about how often monitoring site needs to be changed

Retractions

-The increase of muscle effort results in collapsed soft tissue -Increased respiratory muscle activity to increase tidal volumes >Suprasternal retractions >Intercostal retractions >Substernal or subcostal >Sternal retractions -Suprasternal and sternal/substernal retractions are most commonly found in upper airway obstructions

Special considerations related to Immunizations

-The preferred site for IM injections to infants and young children id the anterolateral thigh -The deltoid can be used on older children -Use a needle long enough to penetrate muscle -SQ injections can be given in the thigh or upper arm -When giving DTaP, Hib and Hepatitis B vaccines at the same time, inject the most reactive one (DTaP in one leg, and inject to others that cause less of a reaction in the other leg -Live bacterial or virus vaccines should NOT be given to immunocompromised children unless under special circumstances -Live measles vaccine is produced by chick embryo cell culture -> possible anaphylaxis in child with EGG ALLERGY -ANY immunization amy cause an anaphylactic reaction -> ALL offices must have epinephrine 1 : 1000 available

Nursing Interventions for Bronchiolitis

-Vital signs and respiratory status every 1 to 2 hours -Note the rate, quality, depth of respirations and for adventitious breath sounds and presence of retractions -Humidified O2 at 35%-40% o decrease hypoxia and bronchial edema -Position the infant's head 30 - 40 degrees upright with neck slightly hyperextended Prevent transmission by placing infant with other RSV infants -CONTACT PRECAUTIONS -Meticulous HAND HYGIENE -Maintain fluid balance -usually PO fluids but may have IV fluids if there is a risk for aspiration with severe conditions -Since there will be a lot of serous nasal drainage, teach parents how to drop normal saline in the nares and bulb suction before meals. -Do not check skin turgor in little ones, check their fontanels -> anterior fontanel is the last one to close at 16-18 months old. A bulging or sunken fontanel causes concern. -Monitor for fever every 2-4 hours -Control environmental temperature (72-75 F) -Liquid acetaminophen or ibuprofen as ordered to reduce fever -Decrease anxiety

Emancipated minors

A person who is under the legal age in a given state but, because of other circumstances, is legally considered an adult.(16-18 yr) -> they do NOT need parents signature for care

Cultural Assessment that is important in providing effective care

ASSESS -Ethnic affiliation -Values, practices, customs -Language barriers -Child-rearing practices -Religious and spiritual beliefs -Nutrition and food patterns -Ethnic health care practices

Epiglottitis

Acute inflammation and swelling of the epiglottis and surrounding tissue -Life threatening and RAPIDLY PROGRESSIVE condition that can cause complete airway obstruction within a few hours of onset -Usually caused by H.influenzae Manifestations -Abrupt onset with rapid progression -Awaken in the night with sore throat and difficulty swallowing -High fever -Can progress to respiratory distress in hours -Anxious, frightened, irritable, or lethargic -Child insists on sitting upright in tripod position (leaning forward supported by arms) with chin thrust out with mouth open -Nasal flaring -Retractions -Pale skin or cyanosis -Tachycardia -edematous and cherry red epiglottis CARDINAL SIGNS (4 D's) -Drooling -Dysphagia (difficulty swallowing) -Dysphonia (Difficulty talking) -Distressed INSPIRATORY efforts -DO NOT examine or obtain culture material from a child's throat because any stimulation could trigger COMPLETE AIRWAY OBSTRUCTION Therapeutic management -Achieve a patent airway -All invasive procedures postponed until child is intubated -Monitor ABGs and O2 saturation -Antibiotics AFTER culture -Antipyretics

Acute tracheitis

Affects 1 month to 6 yr olds -Mucosa of upper trachea swelling -Most common cause is Staphylococcus Assessment -Progresses from upper respiratory infection (1-2 days) -High fever -Stridor -Croupy cough -Purulent secretions Treatment -Humidified O2 -Antipyretics -IV antibiotics -May require intubation

Types of Croup: Acute spasmodic Laryngitis (Spasmodic Croup)

Affects 1-3 yr olds -Subglottic (below the vocal cords) swelling -Caused by viral, emotional, or genetic predisposition Assessment -Sudden onset, usually at night -Child awakens with harsh cough, inspiratory stridor, dyspnea, and hoarseness Treatment -May treat at home -Increased fluids -Calm environment -Cool night air

Types of Croup: Acute Laryngotracheobronchitis (Ltb)

Affects 3 month to 3 yr old -Vocal cord, subglottic, and tissue below the vocal cords, including bronchial swelling -Usually caused by virus but may be bacterial Assessment -Gradual onset, usually at night -Child awakens with harsh cough and inspiratory stridor -Fever Treatment -Racemic epinephrine -IV fluids during respiratory distress -Hospitalization may be necessary

Acute epiglottitis

Affects 3-7 yr olds -Supraglottic (above vocal cords) swelling -Bacterial (usually Hib) Assessment -Sudden onset -> can rapidly progress to COMPLETE AIRWAY OBSTRUCTION AND DEATH -Thumb sign on X-ray -Sore throat -Dyspnea -HIGH fever -Irritable and lethargic Treatment -IV antibiotics -Artificial airway -IV fluids -Emergency HOSPITALIZATION -Intubation equipment at bedside

Nursing Interventions CF

Airway clearance and gas exchange -CPT 2-3 times a day, 1-2 hours AFTER MEALS -Administer bronchodilators and mucolytics before or during CPT -Administer antibiotics AFTERWARD -Monitor respiratory status before and after CPT -Teach huff cough to mobilize secretions -Humidified low-flow (2/L or less) oxygen as ordered -Dyspnea -> elevate HOB or support child in upright position -Stay with child during coughing episodes Preventing infection -IV antibiotics -Educate and practice hand hygiene -Monitor for s/sx of respiratory infection (fever, chills, increased respirations, dyspnea, cough, purulent secretions, increased WBC count) -Keep clients away from ill people -Routine immunizations including and annual influenza vaccine Providing optimal nutrition for growth -Well-balanced diet high in calories, protein, and carbohydrates including the child's favorite foods -Oral or enteral high-calorie supplements can increase the child's caloric intake -Pancreatic enzymes within 30 MINUTES of eating ALL meals or snacks -Do not take with hot foods because heat inactivates enzymes -If child cannot swallow -> mix with non-protein, non acidic food -Wipe any remaining medicine from child's lips because it may be excoriating -Educate family to note the color, consistency, and frequency of the child's stool because enzyme replacement correlates with child's bowel elimination -INCREASE enzyme dosage with high fat foods -Administer vitamins as needed -Monitor child's appetite and food intake -EXTRA FLUID AND SALT when the weather is hot Promote increased exercise tolerance -Group nursing activities to ensure periods of undisturbed rest -Increase activity level as tolerated -Encourage active play and activities such as swimming and gymnastics Meeting the child's and family's emotional needs -Encourage child to express feelings -Identify a support system -Help child identify personal strengths -Teach parents to foster child's independence -Provide family with honest information about the disease and prognosis Home care -Teach family how to carry out CPT, how to provide breathing treatments, and how to give medications at home

Nursing considerations for epiglottitis

Assess for s/sx of respiratory distress -Stridor -Nasal flaring -tachypnea -Tachycardia -Retractions -Drooling -Changes in LOC -Cyanosis -Sudden decrease in respiratory effort -> impending respiratory arrest -Keep child calm -Maintain patent airway -Take axillary or tympanic temperature rather than oral -Allow child to sit up (NEVER force to lie down) -Encourage parents to comfort child and allow child to sit in their laps -Humidified O2 (parents may have to hold it to the child's face) -Explain all procedures plainly and clearly -Emergency intubation equipment at bedside -Report worsening condition to Physician -RECTAL antipyretics -NPO -> IV fluids -> closely monitor IV rate and I's and O's as well as specific gravity -Observe for respiratory distress and suction airway as needed -Once intubated -> restrain and sedate child to avoid extubation -Tube is kept in place 24-48 hours and kept in a mist tent for 24 hours after extubation -Teach parents how to administer oral antibiotics, encourage H, influenzae vaccination -Prophylaxis with rifampin to under-immunized contacts or family under 4 yr old

Clubbing

Bulbous enlargement of distal phalanges of fingers and toes that occurs with chronic hypoxemia -Base of nails swollen -Ends of digits increase in size -Angle between nail and nail bed is 180 degrees or GREATER

Nutrition and activity

Carbohydrates -Provide most of needed energy -Complex carbs can be found in starch from cereal, roots, vegetables, and legumes -Carbs are a food source for vitamin C, E and most B vitamins and potassium Fats -Secondary source of energy -Dietary fat allows the absorption of fat soluble vitamins (ADEK) -Regulates body temperature, Protects internal organs -Teach families to choose lean meats, beans, and low-fat dairy products and limit intake of processed foods Proteins -Necessary for building and maintaining body tissues -Maintains fluid balance -Aid in regulation of immune system -Helps transport many vitamins and minerals Water -Essential for life -Transports nutrients to cells and waste products away from cells -Assists in chemical reactions and regulation of body temperature -Lubricates joints -Found in most foods -Child's activity level and ambient temperature influence the amount of water needed Vitamins and minerals -Regulate metabolic processes -Present in a wide variety of foods -Supplementation is usually NOT needed after infancy (except vitamin D) Dietary guidelines -The my plate system provides food-based guidance to help implement the recommendations of the guidelines -My plate focuses on eating various foods to get the required nutrients and adequate energy Fat intake -NOT restricted for children under 2 -30-35% of calories for children 2-3 -25-35 of calories for children and adolescents 4-18

Apnea

Cessation of breathing for 20 seconds or longer accompanied by bradycardia or cyanosis -Brief periods of apnea (10-15 seconds) are regular for the neonate -> "Periodic breathing" BRUE (Brief resolved unexplained events) -Sudden events of apnea, a color change, a change in muscle tone, or an altered state of responsiveness in an infant who is otherwise HEALTHY and RETURNS TO NORMAL BEHAVIOR after the event -Often occurs in infants older than 2 months but younger than 1 year (may have been born prematurely) -Make sure to rule out underlying issues >Choking >Cardiac issues >Lung issues >Fistulas >Regurgitation ->Teach parents CPR to help them feel safer ->Maintain a neutral thermal environment and avoid suctioning -> monitor closely when feeding -Brief observation period after the event from 1-4 hours with possible pulse ox -PCP follows up in 24 hours

Healthy vs Dysfunctional families

Coping with stress -Stressors change the balance of the family -Stressors are neutral until interpreted by the family as positive or negative Healthy families -Able to mobilize their strengths and resources -> effective adapting to stressors Dysfunctional families -Families fall apart Nurses helping with stressors -Can help the family identify its strengths and resources -Family functional patterns that existed before a crisis are probably the best indicators of how the family will respond to it

Types of play

Dramatic play -Allows children to act out roles and experiences that have happened to them, they fear will happen, or have observed -Nurses may structure this type of play to review a specific type of procedure or treatment -Specialized kits may be provided for certain procedures Familiarization play -Allows children to handle and explore healthcare materials in a fun and non threatening way -May help prepare children with procedures and the whole experience of hospitalization

Croup Interventions

Facilitate airway clearance -Monitor for s/sx of respiratory distress (increased respiratory rate, stridor at rest, nasal flaring, retractions, cyanosis, changes in LOC, or increased irritability, adventitious breath sounds, tachypnea) -If epiglottis is suspected -> DO NOT inspect the throat because that can cause laryngospasm and airway obstruction-> contact PCP -Humidified O2 -VItal signs frequently -Intubation equipment at bedside (intubation tray, O2, suction, manual resuscitation bag-valve-mask) -Aerosolized racemic epinephrine -> decreased laryngeal spasm -> make sure to observe for RECURRENCE of obstruction (REBOUND RESPONSE) that may occur within a few hours after administration -> observe for 4 HOURS -Dexamethasone -> anti inflammatory Maintain fluid balance -Tachypnea -> insensible fluid loss -Difficulty swallowing -> decreased intake -Monitor I's and Os and specific gravity -Check mucous membranes, skin turgor, and presence of tears -DAILY WEIGHTS -Offer clear room temperature liquids in absence of respiratory distress -Observe ability to swallow -IV fluids in the ACUTE phase of croup because oral fluids may cause ASPIRATION -Take temperature every HOURS and administer acetaminophen as ORDERED Decrease fear -Restful environment, bother child as little as possible -Encourage family to touch and cuddle the child -Encourage parents to participate in care and take breaks Provide teaching -Croup may RECUR -Maintain a stable temperature and humidity and HYDRATION will help DECREASE attacks -Avoid large groups of people -Teach s/sx of respiratory distress and to call the PCP >Dyspnea, worsening symptoms >Retractions (tugging of the skin between, above, or below the ribs with INSPIRATION) >Lips turning bluish or dusky 0Breathing cool or warm mist does NOT improve symptoms in 20 minutes >Inability to drink much over the past 24 hours) >DROOLING or difficulty swallowing >Fever (greater than 103 F [39.4 C] >Lethargy, listlessness, or severe agitation -Hydration and nutrition are important -Acetaminophen or ibuprofen is effective in reducing fever -AVOID cough syrups and cold medicines because they can dry or thicken secretions

Kohlberg's stages of MORAL development

INFANCY Naivete and Egocentrism (0-2 yr) -NO moral sensitivity -Decisions are made based on what pleases the child -Infants like or love what helps them and dislikes= what hurts them -No awareness of the effect of their actions on others -"Good is what I like and want" TODDLERHOOD -Punishment-Obedience Orientation (2-3 yr) -Right or wrong is determined by physical consequences -"If i get caught and punished for doing it, it is wrong, if I am not caught and punished, it must be right." PRESCHOOL AGE Hedonism and Concrete reciprocity (4-7 yr) -Child conforms to rules out of self-interest -"I'll do this for you if you do this for me." -Behavior is guided by "an eye for an eye" orientation -"If you do something bad to me, then it is OK for me to do something bad to you." SCHOOL AGE Good-Girl/Boy Orientation (7-10 yr) -Morality is based on avoiding disapproval or disturbing the conscience -Child is becoming socially sensitive Law and Order Orientation (10-12 yr) -Right takes on religious or metaphysical quality -Child wants to show respect for authority, and maintain social order -Obeys rules for their own sake ADOLESCENCE Social Contract Orientation -Right is determined by what is best for the majority -Exceptions to rules can be made if the persons welfare is violated -The end no longer justifies the means -Laws are for mutual good and mutual cooperation ADULTHOOD Personal Principle Orientation -Achieved only by the morally mature -Few people reach this level -These people do what they think is right regardless of others opinions, legal sanctions, or personal sacrifice -Actions are guided by internal standards -Integrity is of utmost importance -May be willing to DIE for their beliefs Universal Principle Orientation -This stage is achieved by only a rare few (e.g., Mother Teresa, Gandhi, Socrates) -These individuals transcend the teachings of organized religion and perceive themselves as part of the cosmic order, understand the reason for their existence, and live for their beliefs

Freud's stages of PSYCHOSEXUAL development

INFANCY Oral stage -Mouth is a sensory organ -Infant takes in and explores during oral passive substage (first half of infancy) -Infant strikes out with teeth during oral aggressive substage (latter half of infancy) TODDLERHOOD Anal stage -Major focus on sexual interest on anus -Control of body functions is major feature PRESCHOOL AGE Phallic or Oedipal/Electra stage -Genitals become focus of sexual curiosity -Conscience (superego) develops -Feelings of guilt emerge SCHOOL AGE Latency stage -Sexual feelings are firmly repressed by the conscience (superego) -Period of relative calm ADOLESCENCE + ADULTHOOD Puberty or genital stage -Stimulated by increasing hormone levels -Sexual energy wells up in full force -> personal and family turmoil

Erikson's stages of PSYCHOSOCIAL development

INFANCY Trust vs. Mistrust -Development of the sense that self is good and the world is good when consistent, predictable, reliable care is received -Characterized by hope TODDLERHOOD Autonomy vs. Shame and doubt -Development of the sense of control over the self and body functions -Exerts self -Characterized by will PRESCHOOL AGE INitiative vs. Guilt -DEvelopment of can-do attitude about the self -Behavior becomes goal -directed -Competitive and imaginative -Initiation into gender role -Characterized by purpose SCHOOL AGE Industry vs. Inferiority -Mastering of useful skills and tools of the culture -Learning how to play and work with peers -Charecterized by competence ADOLESCENCE Identity vs. Role confusion -Begins to develop a sense of "I" -> life long process -Peers become of paramount importance-Child gains independence from parents -Charecterized by faith in self ADULTHOOD Intimacy vs. Isolation -Development of the ability to lose the self in genuine mutuality with another -Charecterized by love Generativity vs. Stagnation -Production of ideas and materials through work -Creation of children -Charecterized by care Ego Integrity vs. Despair -Realization that there is order and purpose in life -Charecterized by wisdom

Piaget's periods of COGNITIVE development

INFANCY (Birth - 2 yr old) Sensory motor period -Reflexive behavior is used to adapt to the environment -Egocentric view of the world -Development of object permanence TODDLERHOOD + PRESCHOOL AGE (2-7 yr old) Preoperational thought -Thinking remains egocentric, becomes magical -Thinking is dominated by PERCEPTION SCHOOL AGE (7-11 yr old) Concrete operations -Thinking becomes more systematic and logical -Concrete objects and activities are needed ADOLESCENCE + ADULTHOOD (11-Adulthood) -New ideas can be created -Situations can be analyzed -Use of abstract and futuristic thinking -Understands logical consequences and behavior

Coping strategies of families

INTERNAL STRATEGIES -Relationship strategies >Family group reliance >Greater sharing together >Role flexibility -Cognitive strategies >Normalizing (adapting) -> coming to a new normal after a big change >Controlling the meaning of the problem by reframing and passive reprisal >Joint problem solving >Gaining of information and knowledge -Communication strategies >Being open and honest >Use of humor and laughter EXTERNAL (COMMUNITY) COPING STRATEGIES -Social support strategies >Extended family >Friends >Neighbors >Self-help groups >Formal social supports -Spiritual Strategies >Seeking advice of clergy >Becoming more involved in religious activities >Having faith in God >Prayer

The child's concept of death

Infancy and toddlerhood (0-2 yr) -Cognitive stage -> Sensorimotor -Concept -> Death as loss of the caregiver Early childhood (2-7 yr) -Cognitive stage -> Preoperational -Concept -> Death as a reversible and temporary separation Middle childhood (school-age; 7-12 yr) -Cognitive stage -> Concrete operations -Concept -> Death as sad and irreversible but not necessarily inevitable Adolescence (12+ yr) -Cognitive stage -> Formal operations -Concept -> Death as inevitable and irreversible but often a distant event

Clinical manefestations of respiratory distress

Initial respiratory failure -Anxiety/restlessness are the FIRST signs -Tachypnea/tachycardia as they TRY TO COMPENSATE Early Decompensation -Nasal flaring -Retractions and accessory muscle use -> abdomen may distend while lower sternum contracts, causing a "seesaw" effect -Grunting (signs of distress in infant) -Confusion -Pooling of blood causing darkened discolored areas on child -> LISTEN FOR LUNG SOUNDS -> if there is an absence of sounds -> Impending distress Impending failure -Dyspnea -Bradypnea/bradycardia V(ERY BAD sign in children) -Cyanosis/stupor/coma

RAST for IgE

Measures quantity of IgE antibodies in serum after exposure to specific antigens Normal findings -If the child is not allergic to the antigen, IgE antibody is NOT detected -A test result is positive in relation to a specific antigen if the value is above 400% of control Indications -To identify specific allergens; systemic reactions to insect venom, drugs, and chemicals -To monitor response to desensitization procedures -Performed at the onset of asthma, hay fever, or dermatitis Nursing considerations -Prepare child for peripheral blood sample to be drawn -Determine whether child has undergone any radioisotope tests within past week because such tests can alter the results

Pilocarpine iontophoresis

Measures sweat electrolyte concentration for diagnosis of CF (Cystic Fibrosis) -Sweating is stimulated on the child's forearm with a small electrical current and pilocarpine; a sweat sample is then collected on preweighed, dry, sterile gauze or filter paper and the amounts of sweat sodium and chloride are measured Normal findings Normal chloride: <40 mEq/L Suggestive of CF: 40-60 mEq/L Positive for CF: >60 mEq/L Indications To diagnose CF Nursing considerations -Offer parents and child support -Inform child and parents that the test is painless and usually performed twice for accurate results -Usually unreliable in infants younger than 2wk because it is hard to obtain enough sweat from them

Apnea of Prematurity

Most common type of apnea -Occurs in neonates of 24-32 weeks of gestational age -Onset usually within first 2 weeks of life -> usually resolves by week 37 -DOES NOT PREDICT SIDS Patho -Can be caused by upper airway obstruction, immaturity of central control mechanisms, compliant chest wall, or abnormal response during REM sleep -Often occurs during feeding because of immaturity of breathing, sucking, and swallowing coordination Therapeutic management -Gentle cutaneous stimulation (touch their feet, then sternal rub)to stimulate breathing in neonates with mild apnea (<10 episodes/day with little destauration) -O2 administration, cardiorespiratory monitor, and maybe CPAP for persistent and severe apnea)

Infant Apnea

No known cause, make sure to rule out -Cardiac abnormalities -Gastroesophageal reflux -Seizures -Hypoglycemia -Respiratory infection -Environmental exposure (e.g., cigarette smoke) -Child abuse Three types -Central -> absence of respiratory effort and air movement -Obstructive -> Apparent respiratory efforts without air movement or sound -Mixed -> Absence of respiratory effort and nasal air movement followed by resumption of respiratory effort without air movement Therapeutic management -Identify any underlying cause -If infant returns to normal behavior and there is no underlying cause, no further care is needed -Teach parents CPR

Do chapter 36

Ok i will!

Stages of speration anxiety

Protest -Child is distressed, crying, resists caregivers, is inconsolable Despair -Child feels hopless and becomes quiet and withdrawn -Crying decreases and child becomes apathetic Detachment -Child becomes interested in environment and may ignore parents' return as a coping mechanism to prevent further emotional pain related to the separation -Nurses need to reassure the patient that this is a normal reaction to separation -If seperation can be avoided -> child will be much more resilient during hospitalization

Laryngoscopy

Provided direct viewing of larynx with a scope Normal findings -Normal appearance of larynx Indications -To identify cause of stridor and local abnormalities Nursing considerations -Mirror (indirect laryngoscopy) may be done 4 yr or older -Direct OR transnasal laryngoscopy works best for infants and younger children -General anesthesia is required; topical anesthesia and mild sedation can be provided for fiberoptic examination -Fluids and foods are WITHHELD until effects of local anesthetic wear off and gag reflex has RETURNED

DDST-II (Denver Developmental Screening Test II)

Provides a clinical impression of a child's OVERALL DEVELOPMENT and alerts the user to potential developmental difficulties -it is only a screening test -Personal-social -> Getting along with others/personal needs -Fine motor -> Eye-hand coordination/problem solving -Language -> Hearing, using and understanding language -Gross motor -> Sitting, jumping

Bronchoscopy

Provides viewing of the tracheobronchial tree through a scope Normal findings -Normal appearance of tracheobronchial tree or successful removal of foreign body or mucous plugs Indications -To view a lesion and obtain biopsy material for culture -To remove foreign body or mucous plugs Nursing considerations -Rigid bronchoscopy is usually performed with child under general anesthesia -Flexible tube may be used while child is awake or sedated -Observe child CLOSELY for airway obstruction -Mist may be given to DECREASE swelling and edema

CF manefestations

Respiratory system -Wheezing and a dry nonproductive cough (earliest symptoms) -Repeated bouts of bronchiolitis, pneumonia, and bronchitis -Purulent and copious sputum from chronic bacterial infections -Wet paroxysmal cough followed by vomiting in early stages -As disease progresses -> crackles, wheezes, diminished breath sounds, accessory muscle use, retractions, hypoxia, and cyanosis -Cough increases -Dyspnea and tachypnea -Later changes -> Emphysema, atelectasis (collapse of lung tissue with loss of volume), cor pulmonale and CHF from fibrotic lung changes -> Spontaneous pneumothorax or hemoptysis (blood stained sputum) -Nasal polyps, sinusitis, digital clubbing, and barrel chest Digestive system -Steatorrhea (frothy, foul smelling stools two to three times bulkier than normal) -Flatus -Malnutrition and growth failure despite normal caloric intake -> thin and underweight -Deficiency in FAT SOLUBLE vitamins (A,D,E,K) due to inability to absorb fats -Vitamin A deficiency -> xerophthalmia (abnormal thickening of the eye tissue) -Vitamin K deficiency -> bleeding -Protuberant abdomen, barrel chest, wasted buttocks, and thin extremities -Meconium ileus in the neonate is the earliest manifestation -Intestinal obstruction (meconium ileus equivalent) occurs later in life as feces are impacted at the ileocecal valve -Rectal prolapse and insucception may occur -Liver disease -Diabetes mellitus -Digestive enzymes from pancreas are blocked by thick mucus -> proteins, fats, and carbohydrates are poorly absorbed -Islets of Langerhans of the Pancreas decrease in number as disease progresses -> DM T1 in some clients Exocrine Glands -Abnormally high concentrations of SODIUM and CHLORIDE in the sweat are an early sign of CF -High risk of electrolyte imbalance when there are hot temperatures outside -> HYPOnatremia, HYPOchloremia, and dehydration -Dry mouth -Increased risk for infection Reproductive system -2-year delay in secondary sex characteristics -Difficulty becoming pregnant because of thick cervical mucus (dont rely on this as a birth-control method) -Sterility due to lack of sperm found in 95% of clients with CF

Classifications of play

Sensory motor (functional) play -A child activates or manipulates an object and derives enjoyment from the result -> child repeats -Prominent during infancy Symbolic play (including pretend play) -Child uses an object to represent another -Can help a child adjust to a new or painful experience Games -Include rules and are usually played by more than one person

Chest radiography (posterior, lateral, and anterior views)

Shows airways, lungs, heart, great vessels Normal findings -Normal appearance of internal structures of chest Indications -To detect respiratory disease of lungs Nursing considerations -Assist in holing the child

CT (Computed tomography)

Shows lesions in chest wall, pleural space, mediastinum, and lung parenchyma Normal findings -Normal cross section of lung tissue Indications -To image tumors or masses -To evaluate response to therapy aimed at defined lesions Nursing considerations -Assist with sedation and immobilization of child -Withhold feedings 3-4 hours before the test because of frequent use of contrast medium

Social Aspects of Play

Solitary play -Child plays alone with toys very different than the nearby children -Common in toddlers due to lack of cognitive and physical skills Parallel play -Children play side by side with similar toys but there is a LACK of interactive activity -Common in toddlers Associative play -Group play without goals -May play with the same type of toys and trade toys -Lack of formal organization Cooperative play -Organized and has group goals -Usually at least one leader -Children are definitely in or out of the group Onlooker play -Child observes others playing -Child may ask questions but does not attempt to join the play -Usually during toddler years

SIDS (Sudden Infant Death syndrome)

Sudden unexplained death of an infant younger than 1 year -More common in boys, low-birthweight infants, and infants from lower socioeconomic groups -Occurs more often in the winter months Intrinsic factors -Genetic predisposition -Male gender -Prematurity Extrinsic factors (modifiable) -Prone sleeping position -Bed sharing -Use of soft bed clothes or mattresses -Putting the infant to sleep on upholstered furniture or adult mattress -Pre/postnatal exposure to cigarette smoke or alcohol Prevention (EDUCATE PARENTS ABOUT THIS) -Make the baby sleep supine -Avoid bed sharing -Put the baby in its own crib or bassinet in the parents room for 6 months minimum -Use firm mattresses fitted to the bed frame -NOTHING goes in the crib with the baby -> use the babies sleepwear to keep the baby warm -Provide a pacifier to sleep (wait a few weeks after breast feeding has started to introduce the pacifier) -DO NOT put infant to sleep anywhere other than their crib -If infants are carried in a sling -> Make sure no fabric is blocking the infant's mouth or nose Interventions -Emotional support -Allow parents to say goodbye to child -Explain that an autopsy is needed to confirm cause of death -Referral to local information, support and counseling

Patterns of growth and development

The normal pace of growth for all children falls into four distinct patterns 1. Rapid pace from birth to 2 years 2. Slower pace from 2 years to puberty 3. Rapid pace from puberty to 15 years old 4. Sharp decline from 15 to 24 years -The first direction of growth is cephalocaudal (head to toe) -Second direction is proximodistal (from the center outward) -Functions progress from simple to complex -Developmental stages DO NOT always correlate with chronological age

Common misconceptions about contraindications to vaccines

These are NOT contraindications to vaccines: -Mild-acute illness with low-grade fever or mild diarrhea in an otherwise healthy child -A reaction to a previous dose of DTaP vaccine with ONLY soreness, redness, or swelling in the immediate vicinity of the injection site

Discipline/ Dealing with misbehavior

Three essential components of effective discipline -Maintain a supportive, loving relationship between the parents and the child -Positive reinforcement and encouragement to promote cooperation and desired behaviors -Removing reinforcement or applying punishment to reduce or eliminate undesired behaviors *Spanking is discouraged Types of discipline -Reasoning -> explaining why the behavior is not permitted >The behavior should be the object of focus, not the child -Time-out -> removes attention from the misbehaving child >Usually 1 minute per year of age -Consequences -> helps children learn direct results of misbehavior >Natural, Logical, and unrelated -Behavior modification -> rewards positive behavior and ignores negative behavior >This system should continue for several months until a habit is formed >CONSISTENCY IS KEY -Corporal punishment >Usually spanking >Highly discouraged >May lead to depression, substance use, and domestic violence

Cultures

Throat, blood, nasopharyngeal, sputum, induced sputum Normal findings -No culture growth or normal flora ONLY Indications -To isolate and identify pathogens

Safety

Unintentional injury is the LEADING cause of death in children -MVA and drowning are the most common -All children are at risk for injury because of their normal curiosity, impulsiveness, and impatience Nurses can provide anticipatory guidance -MUST gear education strategies to the child's level of growth and development -Parents need to know how to provide a safe environment for their children and what behaviors they can expect at various developmental levels -Awareness of the child's changing capabilities allows the parent to become more alert and reactive to safety hazards that the child may encounter -Focus on SPECIFIC PROBLEMS with SPECIFIC SOLUTIONS rather than providing broad or vague advice -DOCUMENT TEACHING and how many times parents were taught -Make sure clients are safe in the hospital under your care

Bronchiolitis (RSV) Patho

Upper respiratory infection usually caused by PSV -> Edema, mucous, and cellular debris obstruct bronchioles -> Bronchioles constrict during expiration -> HYPERINFLATION of lungs -> Atelectasis occurs when obstruction is complete and trapped air is absorbed -> Normal exchange of gasses impaired -> Hypoxemia ->Metabolic acidosis, mild respiratory alkalosis

CF Therapeutic management

Usually cared for at home -Hospitalized during acute pulmonary infections, periodically for CPT (chest physiotherapy), and for end-stage disease Respiratory problems -Treatment goals are to relieve airway obstruction by mobilizing secretions, decrease the number of bacteria by removing secretions, and treat infections with antibiotics -ACT (Airway clearance techniques) -> segmental percussion and postural drainage preceded by inhalation therapy -> move secretions to central airways to be expectorated -Regular aerobic exercise such as jogging, swimming, and/or weight training can improve/maintain lung function and prevent exacerbations -Antibiotics (oral) in higher than usual doses due to rapid metabolism of drugs to greatly increase life expectancy -Aerosolized antibiotics for organisms resistant to oral antibiotics (e.g., Pseudomonas aeruginosa) -IV antibiotics at hospital and at home -Steroids to decrease inflammation in the lung when condition is unresponsive to antibiotics and CPT -> may cause growth retardation and altered glucose tolerance -Long-term ibuprofen may delay disease progression Digestive problems -Increased calorie and protein demand due to increase work of breathing and malabsorption -Child's calorie requirements are approximately 150% of recommended daily allowance -High calorie, high-protein diet -Pancreatic enzyme replacement therapy -Fat-soluble vitamin supplements (A,D,E,K) -Fats are NOT restricted unless steatorrhea cannot be controlled -If nutritional problems are severe -> nighttime gastrostomy feedings or TPN (total parenteral nutrition) -Predigested or concentrated formula for infants -Food supplements or enteral tube feedings -Growth hormone to increase height and weight of children -Enteric-coated pancreatic enzyme preparations administered with EVERY MEAL AND SNACK -> dosage is based on stool formation >Constipation -> fewer enzymes >Loose,fatty stools -> MORE enzymes >Keep the dose as low as possible -Histamine-2 blockers or PPis for overly acidic intestines (enzymes will only work in an alkalotic environment) -EXTRA SALT in the diet when the child exercises vigorously

Regression

a reactivation of behavior more appropriate at an EARLIER stage of development as a DEFENCE MECHANISM in stressful situations-> will return to normal once child is removed from stressful situation