Pediatrics Concept Exam 2
26. Best method for assessing rehydration therapy response in child
****weight gain*****
1. Determination of significant findings in dehydrated infant
**Weight loss** Rapid pulse. Decreased blood pressure. Decreased peripheral circulation (cap refill >2 seconds). Decreased urinary output. Increased specific gravity after 3 mo. Decreased skin turgor. Dry mucous membranes. Nursing diagnoses: Deficient fluid volume, Risk for injury, Deficient knowledge. Maintain strict I&O, Oral rehydration solutions first, Administer IV fluids based on type of dehydration. Newborns do NOT cry tears! After this age absence of tears would be concerning. Sunken fotanels up to 18 mo of age. Signs of shock (hypovolemic).
15. MMR (measles mumps and rubella)
12 month Kindergarten
When does their birth weight triple
12 months
15. Varicella (chicken pox)
12 months Kindergarten
15. Rotavirus gastrointestinal problem
2, 4, 6 months.
15. PCV (pneumococcal pneumonia)
2, 4, 6 months. 12 months
15. Hib (Heamophilus influenzas type B)
2, 4, 6, months and booster 12-15 months. Meningitis poster at college
15. IPV (inactive Polio virus)
2, 4, 6, months then Kindergarten.
15. DTap (diphtheria, tetanus, pertussis)
2, 4, 6, months, and booster at 15-18 months then Kindergarten. Offered to pregnant woman
5) When do they rollover
3 or 4 months
MSPI
30% of children have this and are not able to take soy based milk either. Then the more expensive hydrolyzed products are used. Protein is partial broken down so it is easier digested. Metallic is medical grade supply breast milk given to hospitals. No formula should be changed without a doctors order.
When does their birth weight double
6 months
5) when do they stand
9 month pulls to a standing position ATI page 15)
Dehydration
A critical condition that results from the loss of extracellular fluid. Types of dehydration. Hypotonic-loss of water and salt in stool and only water ingested, sodium loss greater than water loss. Isotonic-most common. Isotonic fluids are given. Hypertonic-vomiting and diarrhea with decreased water intake, water loss greater than sodium loss. Lower concentration of Na. Na too high.
Growth
A physiologic increase in size through cell multiplication or differentiation
7. Calculation of daily fluid requirement and minimum urine output by age
A) convert lbs to KG, B) allow 100ml/kg for the first 10 kg of body weight, C) allow 50ml/kg for the second 10 kg of body weight, D) allow 20ml/kg for the remain body weight. Minimum urine output by age: Infant 2ml/kg/hr. Children 1ml/kg/hr. Adults ½ ml/kg/hr
9. Triaging of pediatric patients... Who should the nurse call back first?
ABC first.
5) When do they walk
About 1 year to 15 months
5) When should a child sit unassisted
About 6 months
5) When do they crawl
About 9 months
24. Goal of care for a child with Down Syndrome
Also known as trisomy 21. Page 1391) Maintain bond between parent and child, Identify the unique needs, ongoing communication with the family about the disability, treatments, and medications. Build life skills. "THE GOAL IS FOR THE CHILD OR ADOLESCENT TO DEVELOP THE GREATEST LEVEL OF FUNCTIONING AND SKILLS POSSIBLE TO MAINTAIN DAILY LIVING." PAGE 862. Referral: physical therapy, speech, language, and special education.
18. Acetaminophen poisoning S/S and treatment
Aspirin bleeding (give Vit K). Acetaminophen: hepatic system, Elevated Bilirubin, N-acetylcysteine treatment for overdose.
Toddler: 1-3 year
Autonomy versus shame and doubt.
10. Child admitted with dehydration—what order would nurse expect to receive?
BUN, Creatine, K+, Na, h&h, Electrolyte panel (Na+, K+, Cl-..) CO2 acid below 22- alkalosis above24. Urine studies (specific gravity(not very accurate in child less then 3 mo of age, ketones). Rate depends on degree of dehydration, volume on weight and clinical signs. Isotonic dehydration: treated with isotonic fluids (LR, NS, D5%, D5 ¼ NS). Hypotonic dehydration with hypertonic solutions (D10%, D5 ½ NS, D5 LR). Hypertonic (water). Pedialyte <2years >2 years then gatorade. BMP
33) Assessment that would be concerning for child with IV fluids containing K+
Be sure child is able to void (1-2 ml/kg/hr), Never give more than 40 mEq/L, Never give IV push, give with continuous drip. Also make sure that before giving K+ 1) Check K+ level make sure it is not high, too high can cause cardiac problems 2) make sure they are voiding. If not voiding give bolus and see if they void. Also check BUN and creatine levels to ensure proper kidney functioning. In renal failure they cannot pass K+, If they are in renal failure they cannot excrete it, and it will build in body and K+ will be high, leading to cardiac problems. (Cardiac anomalies)
23. Congenital anomalies and characteristics of child with Down syndrome (2 questions)
CONGENITAL (existing at, and usually before, birth; referring to conditions that are present at birth, regardless of their causation) Congenital heart defects (atrial septal defect, ventricular septal defect). 40% to 45% heart defects: Septal defects. RENAL PROBLEMS. Hirschsprung, tracheoesophageal fistula. Altered immune function. Musculoskeletal Muscles: Hypotonic Joints (very floppy, muscle tone weak. Risk for respiratory issues), Hyperextensible, Atlantoaxial instability: 15%-20%. Sensory. Growth: weight vs.height. Sexual development. Bi-lateral simian creases in the hand.
15. Immunization schedule, contraindications for immunizations (3 questions)
CONTRAINDICATION:No live virus vaccines for immunocompromised, recent blood transfusion, immunoglobin, pregnant. Severe febrile (fever) illness. History of allergic response to vaccine or substance in vacccine (neomycin, gelatin...). Most common side effects of immunization is a fever. A) Hep B, birth 2, 6 month. B) DTap (diphtheria, tetanus, pertussis) 2, 4, 6, months, and booster at 15-18 months then Kindergarten. Offered to pregnant woman. C) IPV (inactive Polio virus 2, 4, 6, months then Kindergarten. D) MMR (measles mumps and rubella) 12 month Kindergarten E) Varicella (chicken pox) 12 months Kindergarten F) PCV (pneumococcal pneumonia) 2, 4, 6 months. 12 months G) Rotavirus gastrointestinal problem, 2, 4, 6 months. H) Hib (Heamophilus influenzas type B) 2, 4, 6, months and booster 12-15 months. Meningitis booster at college I) Influenza 12 months. **(MMR) No Rubella or Varicella until 12 month LIVE VIRUSES!!!*** Watch for side effects. Localized such as redness, pain, and swelling treated with ice, systemic is less frequent which include fever and mild irritability. Children's Tylenol. Seek medical assistance if an allergic reaction occurs: high fever, altered mental state, excessive irritability, lethargy, non-responsive, seizures, difficulty breathing, hives, pale and cool skin.
Roles of the Pediatric Nurse
Caregiver: Advocate: Educator: Researcher: Manager: Leader. Tend to be territorial of the patients because they are the advocate and many patients cannot communicate their needs. Ped nursed are different to their physicians, than med surge and their physicians.
1. Determination of significant findings in dehydrated INFANT EARLY SIGNS
Decrease 5% body weight, sticky dry mucosa membranes, flat fontanels, increased irritability, alert still, shrill/high pitched cry, pale skin, turgor normal to decreased, cap refill < 2 sec, HR normal to increased, BP normal, urine output decreased and dark after after 3 mo.
1. Determination of significant findings in dehydrated INFANT MODERATE SIGNS
Decreased 10% body weight, Dry mucosa membranes, sunken fontanels, weak cry irritable, drowsy sluggish, skin pale gray, skin poor turgor, cap refill 2-3 sec, HR increased, BP normal to low, urine output uliguria,
1. Determination of significant findings in dehydrated INFANT SEVERE SIGNS
Decreased 15% body weight, dry mucosa membranes, sunken fontanels, irritability is passive, appearance is lethargic, cry is quiet, skin is Gray mottled, turgor tents up, cap refill >3 seconds, HR raid/threads, BP low, marked uliguria, Urine output is dark.
14. Assessment for a child with mumps
Fever, headache, and malaise, followed by parotitis (earache worsened by chewing). Swallowing issues, b. Low grade fever c. Anorexia d. Ear pain (worsens when chewing) e. HA f. Bilateral or unilateral parotid gland swelling g. 14-21 day incubation h. Fever/ comfort measures i. No school 9 days after parotid swelling j. Analgesics k. Soft no acidic foods
20. Indications a child has ingested a corrosive agent
GI distress and respiratory complications. Apnea and respiratory distress or arrest.
27. Priority safety teaching for a toddler with a hearing impairment (What nursing diagnosis would apply?)
Have someone from the family in the room to help communicate with them. They have other ways of communicate with them. Regression is a concern. The family needs to investigate home safety measures that protect the child from inadvertent injury. "Supervision may be required at all times.
Adolescent: 12-19 years
Identity versus role confusion.
School-age child: 6-12 years
Industry versus inferiority
Review Erikson's stage of development
Infant: birth-1 year Trust versus mistrust. Toddler: 1-3 years Autonomy versus shame and doubt. Preschooler: 3-6 years Initiative versus guilt. School-age child: 6-12 years Industry versus inferiority. Adolescent: 12-19 years Identity versus role confusion.
Stages of Human Development
Infant: one moth-1 year. Toddler: 1-3 years. Preschooler: 3-6 years. School-age child: 6-12 years. Adolescent: 12-19 years
Preschooler: 3-6 years
Initiative versus guilt
15) test question baby coming in for 15 mo check up what immunization would be expected to give. The assumption is
MMR and Varicella would be expected to give.
Maturity
Maturation: Changes due to genetic inheritance rather than life experiences, illness, or injury
31. Nursing delegation and assignment (which patient should the nurse see first?)
ND must remain with in ND scope of care, and patient must be stable and predictable.
Informed consent includes
Nature of treatment or procedure. Risks of treatment or procedure. Benefits of procedure or treatment. Alternative to procedure Assent: indicates the pediatric patient has been informed about what will happen during care and is willing to have the care performed
Acid-Base Balance and Imbalance
Normal blood pH = 7.35 to 7.45. Acidosis: Blood pH < 7.35= Metabolic acidosis (diarrhea). Alkalosis: Blood pH > 7.45=Metabolic alkalosis (vomiting).
3. Assessment that would be concerning in a 15 month old child
Not tripled birth weight b. Not walking on own or crawling upstairs c. Tower 3 cubes d. Line 3 crayons e. Insert pellet in bottle f. Follow simple commands g. Name familiar object h. Indicates some desires or needs by pointing i. Hug care giver Page 15 and 21 ATI.
17. Nursing implications and side effects of treatment of lead poisoning
Nursing priorities of care—prevention, discharge planning. Prevent complications from multiple injections. Use anesthetic solution with IM. Observe for encephalopathy or toxicity of agents (more medications the greater likelihood of toxicity), institute seizure precautions, EVALUATE I&O and RENAL FUNCTION, maintain hydration. Assess for S/S of lead poisoning, not just lead levels before treatment. Treatment can cause more problems then lead levels.
13. Failure to thrive: S/S and care, nursing diagnosis (3 questions)
On the growth chart anything below 50th percentile, or a drop in two percentiles. Reasons: Inadequate caloric intake, Inadequate absorption, Increased metabolism, Defective utilization. Organic related to child's make up, Non organic related to psychosocial problems such as poverty. S/S: Failure to maintain growth trajectory. Developmental delays. Apathy and listlessness. Signs of neglect. Avoidance of eye to eye contact, apathy. Feeding disorders. Floppy when held. CARE: Provide calories and nutrition for catch up growth. Provide consistent care. Feed baby Q4H for 30 min, Change diaper Q2H. Teach positive feeding techniques, Daily weight and accurate I&O, Home health referral. Nursing diagnosis may include Insufficient Knowledge.
25. Teaching for parents of a child with Fragile X
PAGE 862) early diagnosis so that early interventions can be implemented. Resource referrals: special education, health care and social services. Inform parents about growth and development, anticipatory guidance to raise the child according to developmental level. Provide information about FXS, education on medications that might be used.
6. Expectations regarding regression in hospitalized children
PG 1391. Toddler most effected PG 816. Both physical and emotional. This is an abnormal return to an earlier reaction, that are inappropriate for the current age. A once learned new skill will not be used and they will return to an earlier skill such as not using the toilet, or they may refuse to talk. Consistency will help maintain current progress, while inconsistencies will contribute to regression.
15) Immunizations: at home instructions post immunization
Page 1011) Watch for side effects. Localized such as redness, pain, and swelling treated with ice, systemic is less frequent which include fever and mild irritability. Children's Tylenol. Seek medical assistance if an allergic reaction occurs: high fever, altered mental state, excessive irritability, lethargy, non-responsive, seizures, difficulty breathing, hives, pale and cool skin.
21. Risk for child abuse
Parental characteristics:Age, single parent, unrelated partner. Low self-esteem, poor parenting knowledge, poor role model Characteristics of the child: Age from newborn to 1 year. Physically disabled, hyperactive, premature Environmental characteristics: Social isolation, poor support systems. Chronic stress, poverty, substitute caregivers
30. Assessing and administering pain meds for a PRESCHOOL AGE.
Pediatric pain scale, NIPS, Faces scale over 3 years old with 5 choices, FlACC 2 mo to 7 years. ATI) page 43 Loud cry or screaming, verbal expression of pain, thrashing of extremities, attempt to push away or avoid stimulant, Noncooperation, Clinging to significant person, behaviors occur in anticipation of painful stimulus, request physical comfort. Page 44, children above 3 mo of age, NSAIDS for mild pain, moderate to severe pain, opioid morphine drug of choice. Select least traumatic route. proper dosage, routine over PRN for pain that is expected to last a long time, combine adjuvant with analgesics. Avoid IM, rectal route typically are disliked, Intradermal. Meds used for skin anesthesia prior to procedures. ATRAUMATIC CARE! Brief explanation of procedure then performs it ascent b. Provide comfort after with touch, holding, or toy c. Provide outlets for child d. Allow to take charge e. Let them give med to doll f. Parent administers
12) Dehydration and Electrolyte Disturbances Factors responsible for fluid and electrolyte differences between adults and children
Percentage and distribution of body water. Body surface area (greater the smaller they are). Rate of basal metabolism (greater the insensible loss the smaller they are). Status of kidney function (baby unable to concentrated ursine until 3 months, and up to two years their kidneys are not fully mature.). The younger they are the greater the risk for dehydration. More fluid they are made of, the more they can loose. Fluid follows Fluid. Neonates made up of mostly fluid and that is why the loose weight right after birth.
Family-centered care
Philosophy of care which recognizes the centrality of the family in the child's life and inclusion of the family's contribution and involvement in the plan for and delivery of care.
Development
Physiological, psychosocial, and cognitive changes occurring over one's life span due to growth, maturation, and learning; assumes that orderly and specific situations lead to new activities and behavior patterns
11. What recommendations should be given for a child who has ingested a poisonous substance
Poison control center: 800-222-1222 1) Call first, before initiating any interventions. 2) Assessment TREAT CHILD FIRST! 3) Gastric decontamination 4) Induce vomiting, absorb toxin, or use gastric lavage, depending on the agent ingested EMERGENCY TREATMENT: 1. Assess victim (VS, CPR, seizures). 2. Terminate exposure (empty mouth, flush eyes/skin. 3. Identify poison (question victim/witnesses, collect cues from environment). 4. Prevent poison absorption (place child in side lying position, administer activated charcoal, drug antidote, or gastric lavage
4. At what age would hospitalization and separation from parents be most difficult?
Primary nursing goal: Especially for children younger than 5 years of age. Family-centered care. Parents are not "visitors". Familiar items from home. Play therapy. TODDLERS have the greatest risk of REGRESSION. Hospitalization would be more difficult for toddlers than for infants. Toddlers have regressive concerns.
Cows milk allergies.
Protein (Similac and efamil) in ____________ is in these formulas. May have to go to soy milk or partially hydrolyzed. Multifaceted disorder involving local and systemic GI reaction. GI Diarrhea Vomiting Colic and abdominal pain. Respiratory Cold like symptoms (rhinitis, nasal discharge, bronchitis). Other Eczema, excessive crying.
Atraumatic care
Providing care that minimizes or eliminates physical and psychological distress for children and their families in the health care environment. In pediatrics even BP may be deferred, or IV maybe delayed and other options such as pedialyte might be used. IVs are more difficult in 6 month old. IV order consideration are made with this population. If IV goes bad it can be traumatic. IMs are rare, typically only for immunizations. Preschoolers have fear of bodily injury, we need to watch what we say.
When a Minor Can Give Consent
Reproductive health. Drug and alcohol treatment. Emancipation. Mature minor doctrine. Age of majority 19 in Nebraska
lactose intolerance symptoms
S&S r/t diarrhea, abdominal pain, distention and flatus shortly after ingesting milk products. Treatment similar to cow's milk allergy, change formula to soy or hydrolyzed. This is not systemic but localized to the GI tract. IEg not being released.
16. Signs of early lead poisoning vs late signs, which systems are affected by lead poisoning
SYSTEMS: neurologic, renal, and hematologic systems (bone marrow); poisoning. EARLY: poisoning occurs as low as 5mcg/dl and begins with aggression, hyperactivity, impulsivity, distractibility, hearing impairment, mild intellectual deficits, withdrawal; LATE: high doses poisoning at 45mcg/dl causing developmental delays, lowered IQ, encephalopathy, paralysis, blindness, convulsions, coma, and death.
28. Interventions to help a visually impaired child adapt to hospitalization
Safe environment. Reassurance. Orient the child to surroundings. Encourage independence. Consistency of team member
Two questions on the test about
Sex chromosomes does it effect males, or female. Tuners Syndrome=Tina Turner=female. Missing X chromosome. Klinefelter's= Two XX and Y, Males. Hormone therapy for both. Estrogen for woman and testosterone for men.
Standards of Care
Standards of Professional Performance. ANA: American Nurses Association. SPN: Society of Pediatric Nurses. APA: Academy of Pediatricians. Are the ones who dictate standards of care.
21. Findings suggestive of child abuse (2 questions)
Suggestive behaviors: unkempt appearance, growth failure, inappropriate dress, history of multiple injuries due to lack of supervision. Cuts, bruises, that are in unusual areas in various stages of healing. Areas of back and stomach. Patterns. Wary of physical contact, acting out or withdrawing, inappropriate reaction to pain, fear of going home. Does story change, do the caregivers tell story over and over again. Benevolent communication with other in effort to get other to believe the story, does parent take over communication.
21. Findings suggestive of sexual abuse
Suggestive findings: bruises, bleeding, lacerations of genitalia, anus, mouth or throat, pain with urination, STIs, recurrent UTIs, pregnancy, abdominal pain, eneuresis, encopresis. Suggestive Behaviors: Excessive masturbation, seductive behavior, poor peer relationships, regressive behaviors, substance abuse, suicide attempts
22. Medication and parenting techniques for child with ADHD & side effects of ADHD meds
THERAPEUTIC MANAGEMENT OF ADHD: Classroom. Family education and counseling. Behavioral therapy and/or psychotherapy for the child. Environmental manipulation. Medication: Not all children benefit from pharmacologic therapy. Stimulants-increase dopamine and norepinephrine that leads to stimulation of inhibitory system of CNS. Give small doses initially then gradually increase. Avoid in children with tic-like behaviors due to increase in tics. May be long or short acting. Dextroamphetamine (Dexedrine), amphetamine and dextroamphetamine (Adderall), Methylphenidate (Ritalin), Adderall (mixed amphetamine salts) in extended release, Strattera (selective norephinephrine reuptake inhibitor). need to evaluate for side effects. "Rebound effects". Insomnia, anorexia and weight loss, hypertension. If used over the long term, they may suppress growth. ATI) 294 Assignment the family with behavioral strategies. Positive reinforcement, rewards for good behavior, age appropriate consequences. 295 environmental modifications structured environment, decrease stimulus, modeling + behaviors, using steps when assigning chores. Consistent study area. Medication management, and therapy shows greatest results. CAFFEINE AND CHOCOLATE WORSENS SYMPTOMS.
19. Teaching regarding chicken pox
Transmitted by direct contact, by droplet in secretions of respiratory tract, skin lesions. Communicable 1 day before eruption to formation of crusts. Signs: slight fever, malaise, anorexia, pruritic rash with maculopapular vesicular lesions starting on face, back, then extremities. Complications: Secondary bacterial infections (abcesses, cellulitis, pneumonia, sepsis), encephalitis. Nursing care: Maintain standard, airborne, and contact precautions, isolate until lesions crusted, adminster skin care to reduce itching. Produrmal signs, contagious at this time, temp or running nose.
29. Preoperative teaching for a child with retinoblastoma
Tumor arise from the retina. White reflex seen in pictures. Blindness may occur. The eye removal may be needed. Temporary eye will be used due to swelling. Prepare parents for facial edema, eye patch, sphere in place to maintain socket space until prosthesis fitted in 3 weeks. As child ages and grows, new prosthesis maybe needed.
informed consent
Varies in each state. 18 to 19 typically 18 is where __________ _________ can be given. Assent must be given by the pediatric patient in developmentally appropriate terms they need to be informed about what is happening (this varies by age) 5 year old maybe informed by using dolls, pictures just before surgery, not a day as this may lead to a day to perseverate on. A teenage can have anticipatory teaching, where the 5 year old not so much.
Informed Consent Is Not Required when
When the parent or guardian cannot be located. For evaluation and treatment of physical or sexual abuse
Food allergies or intolerances
___________________. Immunoglobulin E (IgE)-(cell mediated response) mediated immune response (e.g., cow's milk allergy). Reactions involving immunologic mechanisms—IgE, may be immediate or delayed and mild or severe (anaphylaxis). Common allergens include peanuts, milk, eggs, wheat, fruits. Diagnostic tests: stool for blood (frank or occult), serum IgE levels, skin prick testing. When an allergen is ingested. IgE is released, stimulates histamine response from mast cells. This is what triggers the reaction. Systemic. No allergy test typically before two especially if they may outgrow them. Also we want to provide a traumatic care, and while testing they may experience anaphylaxis reaction.
2. When working with parents of a child with chronic illness (How should they treat child with a chronic illness?)
a. Not allow child to become dependent for ADLS b. Allow to make choices and participate in self-care activities c. Educate about healthy coping mech- listening, gain knowledge d. Keep involved with peers for coping, play and attend school e. Set routine f. Not reacting to regression g. Express feelings h. Praise child for attempt of self care i. Realistic goals K. "Normalization"—incorporation of diagnosis on family functioning
8. What factors in children are related to Deficient Fluid Volume SELECT ALL THAT APPLY
a. Vomiting b. Diarrhea c. Burns d. Hemorrhage e. Nasogastric suctioning and drainage loss f. NPO due to illness g. Overuse of diuretics or enemas h. Adrenal insufficiency Same causes but they loose fluid quicker then adults.
15. Hep B
birth 2, 6 month.
Infant: birth-1 year
trust vs mistrust