Pediatrics NCLEX

Fever

100.4 considered fever. normal is 97.5 to 98.6. aspirin not given unless prescribed because of risk of Reye's syndrome. retake temp 30-60 min after antipyretic administered.

prescribed IV solution of 5% dextrose and half normal saline 0.45% with 40 mEq of potassium chloride for child with hypotonic dehydration. What is the priority assessment before giving IV prescription?

Check amount of urine output. In hypotonic dehydration, electrolyte imbalance exceeds water loss. before giving potassium chloride IV, check urine output because it should never be given if child has oliguria or anuria. if urine output less than 1-2 mL/kg/hr, potassium chloride should not be given.

best position for surgical repair of cleft lip on right side of lip?

on left side. flat or prone can result in aspiration if client vomits.

Sickle cell anemia regarding precipitating factors related to pain crisis

pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, general stress. encourage fluid intake of 1.5 to 2x the daily requirement to prevent dehydration.

Hepatitis

acute or chronic inflammation of liver caused by a virus, medication reaction, or another disease process. Hepatitis A (HAV): highest incidence with preschool or school age child less than 15 years old. many children asymptomatic, but mild n/v and diarrhea. if asymptomatic, can still spread HAV. Hepatitis B (HBV): most HBV in child acquired perinatally. newborn at risk if mother positive or was a carrier of HBV during pregnancy. routes of maternal fetal (infant) transmission are leakage of virus across placenta late in pregnancy or during labor, ingestion of amniotic fluid or maternal blood, breastfeeding especially if mother has cracked nipples. severity in infant varies from no liver disease to fulminant (severe, acute course) or chronic, active disease. in child and adolescent, HBV occurs in high risk groups: child with hemophilia or other disorders who have received multiple blood transfusions. child or adolescent involved in drug abuse. institutionalized children. preschool age child in endemic areas. child involved in heterosexual activity or sexual activity with homosexual males. HBV infection can cause carrier state and lead to eventual cirrhosis(liver scarring) or hepatocellular carcinoma(malignant liver) during adulthood. Hepatitis C (HCV): transmission primarily parenteral route. some children asymptomatic, but often becomes chronic condition and cause cirrhosis and hepatocellular carcinoma. Hepatitis D (HDV): occurs in children already infected with HBV. acute and chronic forms tend to be more severe than HBV and lead to cirrhosis. child with hemophilia are more likely to be infected, and children who are IV drug users. Hepatitis E (HEV): uncommon in children. not a chronic condition and does not cause chronic liver disease and has no carrier state. Prevention: immunoglobulin provides passive immunity and may be effective for preexposure prophylaxis to prevent HAV infection. Hepatitis B immunoglobulin provides passive immunity and may be effective in preventing infection following one time exposure and should be given immediately after exposure, such as an accidental needle puncture or other contact of infected material with mucous membranes and should also be given to newborns whose mothers are HBsAg- positive. proper handwashing and standard precautions can prevent spread of viral hepatitis. Interventions: strict hand washing. hospitalization required in event of coagulopathy or fulminant hepatitis. standard and enteric precautions are followed during hospitalization. provide enteric precautions for 1 week after onset of jaundice with HAV. hospitalized child not usually isolated in separate room unless fecally incontinent and items likely to become contaminated with feces. children not allowed to share toys. good handwashing for child and parents. clean contaminated household surfaces with bleach. disinfect diaper changing surfaces with 1/4 cup bleach and 1 gallon of water. diapers not changed near surfaces used to prep food. maintain comfort and adequate rest and sleep. low fat, balanced diet. HAV not infectious 1 week after onset of jaundice, so child may return to school at that time or if feeling well. jaundice may get worse before it resolves. caution about administering meds to child. remember liver unable to detoxify and excrete meds. teach signs that indicate worsening of child condition such as change in neurological status, bleeding, and fluid retention.

Diabetes mellitus Data collection, long term effects, and complications

Data collection: polyuria(pee a lot >3L/day), polydipsia(abnormally thirsty), polyphagia(excess or extreme hunger). hyperglycemia. weight loss. unexplained fatigue or lethargy. headache. occasional enuresis(involuntary urination especially at night) in previously toilet trained child. vaginitis in adolescent girls (by candida vaginitis that thrives in hyperglycemic tissues). fruity odor of breath. dehydration. blurred vision. slow wound healing. change in LOC. Longe term effects: failure to grow at normal rate. delayed malnutrition. recurrent infections. neuropathy(disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness). cardiovascular disease. retinal microvascular disease. renal microvascular disease. Complications: hypoglycemia. hyperglycemia. diabetic ketoacidosis. coma. hypo/hyperkalemia. microvascular changes. cardiovascular changes plan to initiate consultation with the diabetic specialist to plan child care.

Diabetes Mellitus: Diet and exercise

Diet: normal, healthy nutrition encouraged. total number of calories based on child age and growth expectations. children with diabetes mellitus need no special foods or supplements. sufficient calories to balance diet expenditure for energy and to satisfy requirement for growth and development. 3 well balanced meals per day at regular intervals. mid afternoon snack and bedtime snack. consistent intake of protein, fats, carbs at each meal and snack needed. concentrated sweets discouraged. fat reduced to 30% or less of total caloric requirement. carry source of glucose (glucose tablets) at all times to treat hypoglycemia. incorporate diet into individualized child needs, likes, dislikes, lifestyle, cultural and socioeconomic patterns. allow child to participate in making food choices to have sense of control. Exercise: extra food consumed when increased activity (10-15g or carbs for every 30-45 min of activity). check BG before exercising plan appropriate exercise regimen and incorporate developmental stage.

Adverse effects of radiation therapy and nursing interventions

GI tract: Anorexia: fluids and foods as best tolerated. small frequent meals. monitor for weight loss. N/V: antiemetics around the clock and monitor for dehydration. Mucosal ulceration: soothing oral hygiene and mouth rinses. Topical anesthetic. Diarrhea: antispasmodics and antidiarrheal. Monitor for dehydration. Skin: Alopecia (hair loss): wig or head wraps. scalp hygiene. head covering in cold weather. Dry or moist Desquamation: keep skin clean. wash skin daily with mild soap sparingly. do not remove skin markings for radiation. avoid sun and extreme temperature changes. for dryness, apply lubricant. Urinary bladder: Cystitis: fluid intake and frequent voiding. monitor for hematuria. Bone marrow: Myelosuppression: monitor for fever. antibiotics. avoid suppositories, enemas, and rectal temperatures. neutropenic or bleeding precautions. monitor for signs of anemia.

Neuroblastoma

if tumor found on adrenal gland(where most tumors develop), findings will be consistent with a firm, nontender, irregular mass in abdomen and this will cause some degree of urinary frequency or retention from compression of bladder, ureter, or kidney.

Diabetes Mellitus: insulin and BG monitoring

Insulin: diluted insulin may be needed for some infants for small enough doses to avoid hypoglycemia. diluted insulin should be labeled to avoid dosage errors. HgbA1C performed every 3 months (reference less than 6%). illness, infection, and stress increases need for insulin and should not be withheld in these situations to prevent hyperglycemia and ketoacidosis. when NPO for procedure, verify with PHCP the need to withhold morning insulin and when food, fluids, and insulin are given. teach insulin administration. teach s/s of hypo/hyperglycemia. teach in administration of glucagon IM or Subcue if hypoglycemic reaction and unable to consume items orally (if semiconscious or unconscious). always have spare bottle of insulin. obtain Medic-Alert bracelet that shows type and daily insulin dosage prescribed. BG monitoring: results provided to maintain glycemic control. more accurate than urine testing. prick several times a day as prescribed. teach proper procedure for obtaining BG. procedure must be precise to have accurate results. hand wash before and after to prevent infection. follow manufacturer instructions. check expiration date on test strips. if BG result isn't reasonable, reread instructions, reassess, check expiration date of strips, and perform again.

Cleft lip and cleft palate

Interventions: check ability to suck, swallow, handle normal secretions, and breathe without distress. monitor fluid and calorie intake daily and monitor weight. modify feeding techniques; use specialized feeding techniques, obturators, and special nipples and feeders. hold upright position and direct formula to side and back of mouth to prevent aspiration. feed small amounts gradually and burp frequently. keep suction equipment and bulb syringe at bedside. teach parents about special feeding or suctioning techniques. teach parents the ESSR method of feeding (enlarge nipple, stimulate sucking reflex, swallow, rest to allow child to finish swallowing what has been placed in mouth). encourage bonding with child, including holding and calling child by name. encourage parents to express feelings about disorder. Preoperative interventions: Cleft lip repair: avoid positioning on side of repair or in prone because these positions can cause rubbing of surgical site on mattress. Position on back upright and position to prevent airway obstruction by secretions, blood, or the tongue. elbow restraints used to prevent infant from injuring or traumatizing surgical site. Cleft palate repair: feed by bottle, breast, or cup or aseptio syringe, or soft cup such as Sippy cup. Oral packing secured to palate and removed in 2-3 days. do not brush teeth. Avoid hard food such as cookies or toast. Soft elbow or jacket restraints to keep child from touching repair site. Remove every 2 hours to check skin integrity and circulation and allow exercising arms. Avoid oral suction or placing objects in mouth such as tongue depressor, thermometer, straws, spoons, forks, pacifiers.

child with type 1 diabetes mellitus brought to emergency department and has abdominal pain and lethargic. Diabetic ketoacidosis diagnosed. What type of IV infusion should be given?

Normal saline (NS). Rehydration is the initial step on resolving diabetic ketoacidosis. NS is the initial IV rehydration fluid. NPH insulin is NEVER given IV. Dextrose solution added to treatment when BG decreases to acceptable level. IV potassium may be given depending on potassium level, but would NOT be part of initial treatment.

Advantages and disadvantages of oxygen delivery systems

Oxygen mask advantages: various sizes available. delivers higher O2 concentration than cannula. able to provide predictable concentration of oxygen if Venturi mask used, whether child breathes through mouth or nose. Oxygen mask disadvantages: skin irritation, fear of suffocation, accumulation of moisture on face. possible of aspiration of vomit. Difficulty with controlling O2 concentrations except with Venturi mask. Nasal Cannula advantages: provides low moderate O2 concentration 22-40%. child able to eat and talk when receiving O2. more complete observation because nose and mouth remain unobstructed. Disadvantages: must have patent nasal airway. May cause abdominal distention, discomfort, or vomiting. difficulty controlling O2 concentration if breathes thru mouth. inability to provide mist is desired. Oxygen tent advantages: provides lower O2 concentration (F10 2 up to 0.3-0.5). child able to receive desired inspired O2 concentrations even when eating. Disadvantages: needs proper fit around bed to prevent leakage of oxygen. cool and wet tent environment. poor access to child; inspired O2 levels fall when tent entered. Oxygen hood advantages: provides higher O2 concentrations (F10 2 up to 1.00). free access to chest for assessment. Disadvantages: high humidity environment. need to remove child for feeding and care.

Data collection Hepatitis

Prodromal or Anicteric Phase: lasts 5-7 days. absence of jaundice. anorexia, malaise, lethargy, and easy fatigability. fever especially among adolescents. N/V. epigastric or right upper quadrant abdominal pain. arthralgia(joint pain) and skin rashes (more likely with hepatitis B). hepatomegaly. Icteric phase: jaundice, best assessed in sclera, nail beds, mucous membranes. dark urine and pale stools. pruritus.

Diabetes Mellitus: Urine testing, Hypo/Hyperglycemia, diabetic ketoacidosis, Interventions

Urine testing: test urine for ketones and glucose. second voided urine specimen is most accurate. ketones in urine can indicate ketoacidosis. unreliable method for BG monitoring. Should be tested for ketones when child ill or when BG greater than 200 or as specified by PHCP. Hypoglycemia: BG less than 70. As a result of too much insulin, not enough food, or excess activity. signs are headache, nausea, sweating, tremors, lethargy, hunger, confusion, slurred speech, tingling around mouth, anxiety. Hyperglycemia: BG greater than 200. signs are polydipsia, polyuria, polyphagia, blurred vision, weak, weight loss, syncope. Diabetic Ketoacidosis: complication of diabetes mellitus when severe insulin deficiency. life threatening. hyperglycemia that progressed to metabolic acidosis occurs. develops over period of several hours to days. BG is more than 300. urine and serum ketones are positive. manifestations are hyperglycemia signs, Kussmaul's respirations(labored, deeper breathing rate), acetone fruity breath odor, increasing lethargy, decreased LOC. Diabetic Ketoacidosis Interventions: goal to restore circulating volume and protect against cerebral, coronary, or renal hypoperfusion. dehydration corrected with IV 0.9% or 0.45% saline. hyperglycemia corrected with IV regular insulin. monitor vitals, urine output, and mental status. correct acidosis and electrolyte imbalances. oxygen. monitor BG. monitor potassium because when child receives insulin to lower BG, potassium will change. if potassium decreases, potassium replacement may be needed. child should void adequately before giving potassium because if not having adequate output, hyperkalemia can result. monitor for fluid overload. IV dextrose added when BG reaches appropriate level. cause of hyperglycemia treated.

PKU

a genetic disorder that results in CNS damage from toxic level of phenylalanine in blood, NOT GI. an autosomal-recessive disorder treated with dietary restriction of phenylalanine intake. All 50 states require screening newborn for PKU.

Impetigo

a highly contagious, bacterial skin infection caused by B-hemolytic streptococci, or staphylococcus aureus, or both. lesions progress to exudative and crusting stage; after crusting of lesions, the initially serous vesicular fluid becomes cloudy, and vesicles rupture, leaving a honey colored crust that covers an ulcerated base. Interventions: contact isolation. Use standard precautions and implement agency-specific isolation procedures for hospitalized child. strict hygiene because it is highly contagious. teach parents methods to prevent spread of infection, especially careful hand washing. child needs to use separate towels, linens, and dishes. all linens and clothing used by child should be washed with detergent in hot water separately from linens and clothing of other household members.

Diarrhea

acute diarrhea is a cause of dehydration, particularly in children younger than 5 years. Some causes of chronic diarrhea include rotavirus, malabsorption syndromes, inflammatory bowel disease, immune deficiencies, food intolerances, and nonspecific factors. Rotavirus is a cause of serious gastroenteritis and is a nosocomial (hospital acquired) pathogen that is most severe in ages 3-24 months; children younger than 3 months have some protection because of maternally acquired antibodies. Intervention: enteric isolation as required. teach parents and child effective handwashing technique. monitor strict I&O. for severe dehydration, NPO status prescribed to place bowel at rest and fluid and electrolyte replacement by IV may be prescribed. if IV potassium prescribed ensure child has voided before administration and has adequate kidney function. major concern of child having diarrhea is risk of dehydration, loss of electrolytes, and development of metabolic acidosis.

Sick Day Rules for Diabetic Child

always give insulin even if child has no appetite, or contact PHCP for specific instructions. test BG every 4 hours. test for urinary ketones with each voiding. notify PHCP if moderate or large amounts of urinary ketones present. follow child usual meal plan. fluids to aid in clearing ketones. rest especially if ketones present. notify PHCP if vomiting, fruity breath odor, deep rapid respirations, decreasing LOC, or persistent hyperglycemia occurs.

B-thalassemia major

an autosomal recessive disorder characterized by reduced production of one of the globin chains in synthesis of hemoglobin. both parents must be carriers to produce child with B-thalassemia major. incidence highest in individuals of mediterranean descent, such as Italians, Greek, Syrians, and their offspring. Data collection: frontal bossing, maxillary prominence, wide wet eyes with flat nose, green/yellow skin tone, hepatosplenomegaly, severe anemia, and Microcytic, hypochromic RBC.

Gastroesophageal Reflux

backflow of gastric contents into esophagus from relaxation or incompetence of lower esophageal or cardiac sphincter. Gastroesophageal reflux disease (GERD): when gastric contents reflux into esophagus or oropharynx and produce symptoms. Data collection: can sometimes cause hematemesis. Interventions: monitor amounts and characteristics of emesis. monitor relationship of vomiting to times of feeding and infant activity. monitor breath sounds before and after feedings. monitor for signs of aspiration such as drooling, coughing, or dyspnea following feeding. place suction equipment at bedside. monitor I&O. monitor for signs and symptoms of dehydration. maintain IV fluids. complications of GERD: esophagitis, esophageal strictures, aspiration of gastric contents, and aspiration pneumonia. Diet: burp infant frequently when feeding and handle infant minimally after feedings. monitor for coughing during feeding and other signs of aspiration. do not feed child fatty foods, chocolate, tomato products, carbonated liquids, fruit juices, citrus products, and spicy foods.

Epiglottis

bacterial form of croup. child immunized with Hib vaccine is less at risk. often occurs in winter. emergency situation because can progress to severe respiratory distress. Data collection: high fever. sore, red, inflamed throat and pain during swallowing. large, cherry red, edematous epiglottis. absence of spontaneous cough. dysphonia (muffled voice), dysphagia, dyspnea, drooling. agitation. retractions and child struggles to breathe. inspiratory stridor aggravated by supine position. tachycardia. tachypnea progressing to more severe respiratory distress (hypoxia, hypercapnia(excessive carbon dioxide in the bloodstream), respiratory acidosis, decreased LOC). tripod positioning : while supporting body with hands, child leans forward, opens mouth to widen airway. Interventions: patent airway maintained. monitor respiratory status and breath sounds, noting nasal flare, use of accessory muscles, retractions, and presence of stridor. do not take oral temp. monitor pulse ox. prep child for lateral neck films to confirm diagnosis and accompany child to radiology department. maintain NPO. do not leave child unattended. avoid supine position because further affects respiratory status. do not restrain child or agitate. IV fluids, insertion of IV may be delayed until adequate airway established because may agitate child. IV antibiotics and usually followed by oral antibiotics. analgesics and antipyretics (acetaminophen or ibuprofen) to reduce fever and throat pain. corticosteroids to reduce inflammation and throat edema. meds that promote mucosal vasoconstriction and reduce edema. cool mist oxygen therapy; high humidification cools airway and decreases swelling. resuscitation equipment available and prep for endotracheal intubation or tracheotomy for severe respiratory distress. ensure child up to date with immunization schedule, including Hib conjugate vaccine. if epiglottis suspected, no attempts should be made to visualize posterior pharynx, obtain a throat culture, or take oral temp. Otherwise, spasm of epiglottis can occur, leading to complete airway occlusion.

High fiber foods

bread and grains: whole grain bread or rolls, whole grain cereals, bran, pancakes, waffles, muffins with fruit or bran, unrefined brown rice. Vegetables: raw vegetables especially broccoli, cabbage, carrots, cauliflower, celery, lettuce, and spinach. cooked vegetables, asparagus, beans, brussels sprouts, corn, potatoes, rhubarb, squash, string beans, turnips. Fruits: prunes, raisins, other dried fruits. raw fruits especially with skin or seeds, other than ripe banana or avocado. Miscellaneous: legumes (beans), popcorn, nuts, seeds. high fiber snack bars.

Strabismus

called squint or cross eyed. Amblyopia ( reduced visual acuity) may occur if not treated early because brain receives 2 messages as a result of nonparallel visual axes. permanent loss of vision if not treated early. this is considered a normal finding in young infant, but it should not be present after age 4 months. muscle imbalance or paralysis of extraocular muscles or congenital are possible causes. Interventions: corrective lenses. good eye patching to strengthen weak eye. surgery usually before age 2 years. if child has this at age 1 year, then they will likely not outgrow this.

A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted? 1. The child has no tears. 2. Urine specific gravity is 1.030. 3. Urine output is less than 1 mL/kg/hour. 4. Capillary refill is less than 2 seconds.

capillary refill is less than 2 seconds. indicators that fluid volume deficit is resolving would be capillary refill less than 2 seconds, specific gravity of 1.002 to 1.025, urine output of at least 1 mL/kg/hr, and adequate tear production. capillary refill of less than 2 seconds is the only indicator that child is improving.

Vomiting

major concerns are risk of dehydration, loss of fluid and electrolytes, and development of metabolic alkalosis. Data collection: signs of aspiration. Interventions: position on side to prevent aspiration. note force of vomiting, because projectile vomiting is indicative of pyloric stenosis or increased ICP. monitor I&O and for signs of dehydration, such as sunken fontanelle (age appropriate), nonelastic skin turgor, dry mucous membranes, decreased tear production, and oliguria.

Ingestions of poisons: Acetylsalicylic acid poisoning

caused by acute or chronic ingestion. Acute: severe toxicity occurs with 300-500 mg/kg. chronic: more than 100mg/kg/day for 2 days or more; can be more serious than acute ingestion. Data collection: GI effects: n/v, and thirst from dehydration. CNS system effects: hyperpnea(increased volume of air when breathing), confused, tinnitus, seizure, coma, respiratory failure, and circulatory collapse. renal effects: oliguria. hematopoietic effects: bleeding tendencies. metabolic effects: diaphoresis, fever, hyponatremia, hypokalemia, dehydration, hypoglycemia. Interventions: prep activated charcoal to decrease salicylate. emesis or cathartic( psychological relief through the open expression of strong emotions) measures. IV fluids; sodium bicarbonate to correct metabolic acidosis. external cooling, anticonvulsants, vitamin K if bleeding, and oxygen. prep for dialysis if unresponsive to therapy.

Intestinal parasites

common infection in child are giardiasis and pinworms. Pinworms intervention: visual inspection of anus with flashlight 2-3 hours after sleep. tape test is most common diagnostic test. loop of transparent tape placed firmly on child perianal area and removed in morning and placed in a glass jar or plastic bag and transported to primary care provider for analysis. meds: ebendazole, pyrantel pamoate, albendazole, but these meds not used in child under 2 years. med regimen repeated in 2 weeks to prevent reinfection. all family members treated for infection. teach meticulous hand washing and washing all clothes and bed linens in hot water.

Hypoglycemia interventions

confirm with BG. give glucose immediately. rapid-releasing glucose followed by complex carbs and protein such as slice of bread or peanut butter cracker. give extra snack if next meal not planned for more than 30 min or activity planned. if becomes unconscious, squeeze cake frosting or glucose paste on gums and retest BG if does not improve in 15 min. if reading remains low, give additional glucose. if remains unconscious, give glucagon, notify PHCP and transport to emergency department. in hospital setting, prep administration of IV dextrose, if child unable to consume oral glucose food: 1/2 cup OJ or sugar sweetened carbonated beverage. 8 oz milk. 1 small box of raisins. 3-4 hard candies. 3 sugar cubes or 1 tbsp of sugar. 3-4 life savers. 1 small candy bar. 1 tsp honey. 2-3 glucose tablets. Priority nursing actions: check BG level. give 1/2 cup fruit juice or other. take vitals. retest BG. small snack of carbs and protein. document child complaints, actions taken, outcome.

Encopresis

constipation with fecal incontinence. children often complain of involuntary soiling without warning. encourage to sit on toilet for 5-10 min 20-30 min after eating.

Aplastic Anemia

deficiency of circulating erythrocytes and all other formed elements in blood, from arrested development of cells within bone marrow. definite diagnosis determined by bone marrow aspiration, which shows the conversion of red bone marrow to yellow fatty bone marrow. Data collection: pancytopenia (deficiency in erythrocytes, leukocytes, and thrombocytes). petechiae, purpura, bleeding, pallor, weakness, tachycardia, fatigue.

caring for child who sustained burn injury and planning on care based on what pediatric considerations associated with this injury?

delay in growth may occur. immature immune system presents an increased risk of infection. infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults. higher proportion of body fluid to body mass increases risk of cardiovascular problems. burns with more than 10% total body surface area require some form of fluid resuscitation.

a school age child with type 1 diabetes mellitus has soccer practice 3x in afternoon. How to prevent hypoglycemia ?

drink half cup of OJ before soccer practice. A snack of 10-15g or carbs eaten before activities for every 30-45 min of activity will prevent hypoglycemia. half cup of OJ will provide enough needed carbs. parents/child should not adjust insulin and meal amounts should not be doubled.

side effects of radiation

dry or moist desquamation (peeling of skin). intervention includes washing skin daily with mild soap and lubricant after.

child has aplastic anemia. Labs are 6000 WBC and 20,000 platelet count. Plan of care?

encourage quiet play activities. WBC is normal and platelet is low. prevent bleeding when platelet count low, so no injections, rectal temp, use soft toothbrush, have quiet activities, abstinence from contact sports or activities that can cause injury. if WBC count low, strict isolation.

Scabies

parasitical skin disorder caused by infestation of Sarcoptes scabiei (itch mite). common in school children and institutionalized population from close personal contact. Lindane shampoo, may be prescribed, and should be used in children younger than 2 years because of risk of neurotoxicity and seizues. pruritic papular rash. burrows into skin (fine grayish red lines that may be hard to see).

Esophageal Atresia and Tracheoesophageal Fistula (TEF)

esophagus terminates before it reaches the stomach , ending in a blind pouch, and/or a fistula is present that forms an unnatural connection with the trachea. causes oral intake to enter lungs or large amount of air to enter stomach. choke, cough, and severe abdominal distention can occur. Data collection: frothy saliva in mouth and nose; drooling. The 3 C's are coughing and choking during feeding and unexplained cyanosis. Preoperative interventions: infant may be placed in radiant warmer in which humidified oxygen given. Maintain supine upright position (at least 30 degrees upright) to facilitate drainage and prevent aspiration of gastric secretions Postoperative interventions: monitor vitals and RR. IV fluids, antibiotics, parenteral nutrition as prescribed. monitor I&O, daily weight, dehydration and fluid overload. monitor for signs of pain. maintain chest tube patency if present. inspect site for infection. monitor for anastomotic leaks as evidenced by purulent drainage from chest tube, increased temp, increased WBC, so report these findings to RN. if gastrostomy tube present, usually attached to gravity drainage until infant can tolerate feedings and the anastomosis is healed (usually postop day 5-7); then feedings prescribed. before oral feeding and removal of chest tube, prep for an esophagram to check integrity of esophageal anastomosis. before feeding, gastrostomy tube elevated and secured above level of stomach to allow gastric secretions to pass to duodenum and swallowed air to escape through open gastrostomy tube. give oral feedings with sterile water, followed by frequent small feedings of formula as prescribed. check cervical esophagostomy site, if present, for redness, breakdown, or exudate; remove accumulated drainage frequently and apply protective ointment, barrier dressing or collection device. provide nonnutritive sucking using pacifier for infants who are NPO for extended periods, but pacifier not used if infant unable to handle secretions. teach parents technique of suctioning, gastrostomy tube care and feedings, and skin site care. teach parents to identify behaviors that indicate need for suctioning, signs of respiratory distress, signs of constricted esophagus(poor feeding, dysphagia or difficulty swallowing, drooling, cough during feeding, regurgitated undigested food).

Leukemia: protecting child from bleeding

examine child for s/s of bleeding. handle child gently. measure abdominal girth which can indicate internal hemorrhage. soft toothbrush and avoid dental brush. soft foods that are cool to warm in temperature. avoid injections to avoid trauma to skin and bleeding. firm and gentle pressure to needle stick site for 10 min. pad side rails and sharp corners of bed and other furniture. do not engage in activities that involve harmful objects. avoid constrictive or tight clothing. use caution when taking BP to avoid skin injury. avoid blowing nose. avoid rectal suppositories, enemas, rectal thermometers. bowel program to prevent constipation and rectal trauma. examine all body fluids and excrement for blood. count number of pads/tampons if menstruating. instruct child regarding s/s of bleeding. avoid nonsteroidal antiinflammatory drugs (NSAIDs)and aspirin.

Ingestions of poisons: Lead Poisoning

excess lead in blood. Causes: pathway for exposure may be food, air, or water. dust and soil contaminated with lead. lead enters child body thru ingestion or inhalation, or through placental transmission to an unborn child when mother is exposed. most common route is hand to mouth from contaminated objects such as loose paint chips, pottery, or ceramicware coupled with inhalation of lead dust in environment. when lead enters body, it affects erythrocytes, bones, teeth, organs, and tissues, including brain and nervous system. most serious consequences are effects on CNS. Universal screening: recommended in high risk areas in ages 1-2 years. Children at high risk should be screened earlier. any child between 3-6 years not screened should be tested. Chelation therapy: removes lead from circulating blood and from some organs and tissues. does not counteract any effects of lead. meds include calcium disodium edetate and succimer, an oral prep. British anti-Lewisite used in conjunction with edetate. British anti-Lewisite give IV or deep IM and contraindicated in children with allergy to peanuts because med is prepped in peanut oil solution; also contraindicated in child with glucose 6-phosphate dehydrogenase (G6PD) deficiency and should not give with iron. function of renal, hepatic, and hematological systems monitored closely. urinary output ensured before giving med and important to monitor output and pH of urine during and after therapy. adequate hydration and monitor kidney for nephrotoxicity when med given because med is excreted by kidneys. follow up of lead levels to monitor progress. teach parents lead hazards and safety, med administration and need for follow up. confirm child will be discharged to home without lead hazards.

Hirschsprung disease

from absence of ganglion cells in rectum and other areas of affected intestine. results in mechanical obstruction because inadequate motility in intestinal segment. rectal biopsy demonstrates absence of ganglionic cells. the most serious complication is enterocolitis; signs include fever, severe prostration(lying stretched out on the ground), GI bleeding, explosive watery diarrhea. Data collection: Newborns: failure to pass meconium stool, refusal to suck, abdominal distention, bile stained vomitus. Child: fail to gain weight and delay growth, abdominal distention, vomiting, constipation alternating with diarrhea, ribbon like and foul smelling stools. Intervention: medical management. Maintain low fiber, high calorie, high protein. parenteral nutrition in extreme situations. stool softeners as prescribed. daily rectal irrigations with NS to promote elimination and prevent obstruction. Postoperative interventions: vitals but avoid taking rectal temperature. measure abdominal girth and PRN. check surgical site for redness, swelling, and drainage. check stoma if present for bleeding or skin breakdown (stoma should be red and moist). check anal area for presence of stool, red, or discharge. NPO until bowel sounds return or flatus passed within 48-72 hours. maintain NG tube to allow intermittent suction until peristalsis returns. IV fluids until child tolerates appropriate oral intake, advancing from clear liquids to regular as tolerated. monitor for dehydration and fluid overload. monitor strict I&O. obtain daily weight. monitor for pain and provide comfort measures. teach parents colostomy care and skin care. teach parents diet and importance of fluid intake.

child has type 1 diabetes and admitted to emergency department for treatment of diabetic ketoacidosis. What should nurse expect to note?

fruity breath odor and decreasing LOC. diabetic ketoacidosis is a complication of diabetes mellitus that develops when severe insulin deficiency occurs. hyperglycemia occurs with diabetic ketoacidosis. signs of hyperglycemia are fruity breath odor and decreasing LOC. Hunger can be from hypo/hyperglycemia. hypertension NOT a sign of diabetic ketoacidosis. Hypotension is from decrease in blood volume related to dehydrated state that occurs during diabetic ketoacidosis. cold clammy skin, irritability, sweating and tremors are all signs of hypoglycemia.

Lactose Intolerance

inability to tolerate lactose as result of absence or deficiency of lactase which is an enzyme found in secretions of small intestine that is required for digestion of lactose. Interventions: eliminate dairy product or give enzyme replacement. enzyme tabs that predigest lactose in milk or supplement body's own lactase. soy based formula can be substituted for cow milk formula or human milk. limit milk to one glass at a time. if milk consumed, should be taken when other foods consumed rather than by itself. consume hard cheese, cottage cheese, or yogurt (which contain inactive lactase enzyme) rather than milk. eat small amounts of dairy foods daily to help colonic bacteria adapt to ingested lactose. child with lactose intolerance can develop calcium and vitamin D deficiency.

interventions for child older than 2 years with type 1 diabetes mellitus with BG of 60?

give teaspoon of honey. prepare to give glucagon subcue if unconscious occurs. hypoglycemia is from too much insulin (less than 70), not enough food, or excess activity. if possible, confirm BG reading. glucose given orally immediately; rapid release glucose followed by complex carbs and protein such as slice of bread or peanut butter cracker. extra snack given if next meal not planned for more than 30 min or activity planned. if unconscious, cake frosting or glucose paste squeezed on gums and BG retested in 15 min; if reading remains low, give more glucose. if remains unconscious, glucagon may be needed. if child ambulates or given regular insulin, it would lower BG even more. electrolyte replacement therapy IV would treat diabetic ketoacidosis. Waiting additional 30 min to confirm BG, would delay necessary intervention.

Hemophilia

group of bleeding disorders from deficiency in specific coagulation proteins. identifying the specific coagulation deficiency is important for treatment . aggressive replacement therapy initiated to prevent chronic crippling effects from joint bleeding. most common types: factor VIII deficiency(hemophilia A or classic hemophilia) and factor IX deficiency(hemophilia B or Christmas disease). transmitted as an X-linked recessive disorder and may also occur as a result from gene mutation. carrier females pass defect to affected males. female offspring rarely born with disorder but may be if inherit an affected gene from their mother and are offspring of father with hemophilia. primary treatment is replacement of missing clot factors; additional meds, such as those that relieve pain or corticosteroids depending on source of bleeding. Data collection: abnormal bleeding from trauma/surgery (sometimes after circumcision), epistaxis (nose bleed), joint bleeding that cause pain/tender/swelling/limited ROM. tendency to bruise easily. test results that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Interventions: monitor bleeding and maintain bleeding precautions. replacement factor as prescribed. DDAVP (1-deamino-8-D-arginine vasopressin), a synthetic form or vasopressin, increases VIII and may be given to treat mild hemophilia. monitor for joint pain and immobilize affected extremity if joint pain occurs. monitor for neurological status because of risk of intracranial hemorrhage. monitor urine for hematuria. control bleeding by immobilization, elevation, and ice application. apply pressure for superficial bleeding. teach signs of internal bleeding and how to control bleeding. teach activities for child and emphasize avoidance of contact sports and protective devices when learning to walk; assist in exercise plan. wear protective devices such as helmets and knee and elbow pads during sports such as bikes and skating.

monitoring infection for leukemia

hand washing. inspect skin daily for redness. inspect mouth daily for lesions. only oral, axillary, temporal, tympanic temp taken. no rectal temp. oral temp avoided if oral lesions

Wilm's Tumor signs and symptoms.

hematuria, hypertension, and fever. Wilms' Tumor is an intraabdominal and kidney tumor. if tumor suspected, mass should not be palpated. excessive manipulation can cause seeding of tumor and spread cancerous cells.

Von Willebrand's Disease

hereditary bleeding disorder - deficiency or defect in a protein called von willebrand factor (vWF). causes platelets to adhere to damaged endothelium. vWF protein also serves as carrier protein for factor VIII. characterized by increased tendency to bleed from mucous membranes. Data collection: epistaxis (nose bleed), gum bleed, easy bruising, excessive menstrual bleed. child needs to wear Medic-Alert bracelet.

Umbilical Hernia

hernia or protrusion of bowel through an abnormal or weakened opening in abdominal wall. in children commonly occurs in umbilicus and inguinal canal. Umbilical hernia: can usually be reduced with the finger. inguinal hernia: painless reducible swelling that may disappear at rest but noticeable when cough or cry. Incarcerated Hernia: when descended portion of bowel becomes tightly caught in hernial sac, compromising blood supply. medical emergency requiring surgical repair. Data collection: contact PHCP if pain, irritability, tender at site, anorexia, abdominal distention, difficulty defecating. signs may lead to complete intestinal obstruction and gangrene. Communicating Hydrocele: hernia that remains open from scrotum to abdominal cavity. Data collection: bulge in inguinal area if scrotum that increases with crying or straining and decreases when child at rest. Postop interventions: ice bags and scrotal support for pain and swelling. avoid tub bathing until incision heals. avoid strenuous physical activities.

Abdominal Wall Defects: Gastroschisis

herniation of intestine is lateral to umbilical ring, usually on the right. no membrane covering exposed bowel. exposed bowel covered loosely in saline soaked pads, and abdomen loosely wrapped in plastic drape or bowel bag; wrapping directly around exposed bowel is contraindicated because if the exposed bowel expands, wrapping could cause pressure and necrosis. surgery several hours after birth because no membrane is covering sac. Preoperatively: maintain NPO. IV fluids for hydration and electrolyte balance. Monitor for infection and handle infant carefully to prevent rupture of sac.

Lessening pain of BG monitoring

hold finger under warm water for few seconds before puncture because it enhances blood flow to finger. use ring finger or thumb to obtain blood sample because blood flows more easily through these areas. puncture just side of finger pad because of more blood vessels and few nerve endings. press lancet lightly against skin to prevent deep puncture. use glucose monitors that require very small blood samples for measurement.

hypertrophic pyloric stenosis

hypertrophy of circular muscles of pylorus causes narrowing of pyloric canal between stomach and duodenum. Data Collection: vomiting that progresses from mild regurgitation to forceful and projectile that usually occurs after feeding. peristaltic waves visible from left to right across the epigastrium during or immediately after a feeding. olive shaped mass in epigastrium just right of umbilicus. projectile, nonbilious vomiting, irritability, hunger and crying, constipation, signs of dehydration, decrease in urine output. Pyloromyotomy: incision through muscle fibers of pylorus, which may be performed by laparoscopy. Interventions preoperatively: monitor hydration status by checking daily weight, I&O, and urine for specific gravity. correct fluid and electrolyte imbalances; IV fluids may be prescribed for rehydration. maintain NPO. monitor number and character of stools. maintain patency of NG tube that is placed for stomach decompression. Interventions postoperatively: monitor I&O. small, frequent feedings. gradually increase amount and interval between feedings until full feeding schedule reinstated. feed infant slow, burp frequently, and handle minimally after feedings. monitor for abdominal distention. monitor surgical wound and signs of infection. teach parents wound care and feeding.

Imperforate anus

incomplete development or absence of the anus in its normal position in the perineum. Data collection: failure to pass meconium stool. absence or stenosis of anal rectal canal. presence of anal membrane. external fistula to the perineum. Preoperative interventions: determine patency of anus. monitor for presence of stool in urine and vagina and report this immediately. Postoperative interventions: preferred position is side lying prone with hips elevated OR supine position with legs suspended 90 degree angle to trunk to reduce edema and pressure on surgical site. colostomy care if prescribed. A new colostomy stoma will be red and edematous, but should decrease with time. anal dilation may be prescribed. Use dilators prescribed by PHCP, water soluble lubricant, and insert dilator 1-2 cm into anus to prevent damage to mucosa.

irritable bowel syndrome

increased motility that leads to spasm and pain. Interventions: problem is self limiting and intermittent and it will resolve. Anticholinergics. antidepressants in severe cases. healthy, well balanced, moderate fiber and low fat diet. encourage health promotion activities such as exercise and school activities. inform parents about psychosocial recourses if required.

Dehydration

infants and children more vulnerable to fluid volume deficits because more of their body water is in extracellular fluid compartment. monitor weight and weight changes, including fluid gains and losses. Level of dehydration: infant weight loss: mild 3-5%, moderate 6-9%, severe greater than or equal to 10%. child weight loss: mild 3-4%, moderate 6-8%, severe 10%. pulse: mild normal, moderate slight increase, severe very increased. RR: mild normal, moderate slight tachypnea(rapid), severe hyperpnea (deep and rapid). BP: mild normal, moderate normal to orthostatic (>10 change), severe orthostatic to shock. behavior: mild normal, moderate irritable and more thirsty, severe hyperirritable to lethargic. thirst: mild slight, moderate is moderate, severe intense. mucous membranes: mild normal, moderate dry, severe parched. tears: mild present, moderate decreased, severe absent; sunken eye. anterior fontanelle: mild normal, moderate normal to sunken, severe sunken. external jugular vein: mild visible when supine, moderate not visible except with supraclavicular pressure, severe not visible even with supraclavicular pressure. skin: mild capillary refill >2 sec, moderate slow capillary refill 2-4 sec and decreased turgor, severe very delayed capillary refill >4 sec and tenting; skin cool and acrocyanotic and mottled. Urine specific gravity: mild >1.020, moderate >1.020; oliguria, severe oliguria or anuria.

meaning of maculopapular lesions behind ears or lesions that extend to hairline or neck

infection

Pediculosis Capitis (lice)

infestation of hair and scalp with lice. all contacts of infested child should be examined for lice infestation and referred for treatment as appropriate. Interventions: use pediculicide as prescribed; follow package instructions for timing application and contraindications for use in children. daily removal of nits with extra fine tooth metal knit comb as a control measure after pediculicide use. gloves worn for removal of nits. hairbrushes or combs discarded or soaked in boiling water for 10 min or commercially lice killing product for 1 hour. siblings may also need treatment. grooming items not shared and single comb or brush should be for each individual child. bedding and clothing used by child should be changed daily, laundered in hot water with detergent, and dried in hot drier for 20 min and this process continued for 1 week. nonessential clothing and bedding stored in tightly sealed bag for 2 weeks and then washed. seal toys that cannot be washed or dry cleaned in plastic bag for 2 weeks. furniture and carpets need to be vacuumed frequently and dust bag from vacuum should be discarded after vacuuming. child must not share clothing, headwear, brushes and combs. lice of eyebrows and eyelashes may need to be removed manually.

Otitis media

inflammation disorder of middle ear from blocked eustachian tube, which prevents normal drainage; can be acute or chronic. common complication of acute respiratory infection, most commonly from syncytial virus orsa influenza. infant and child more prone to this because eustachian tube is shorter, wider, and straighter. Prevention: feed infant in upright position to avoid reflux. encourage breastfeed for first 6 months Data collection: purulent ear drainage may be present. red, opaque, bulging, immobile tympanic membrane on otoscopic exam. signs of hearing loss indicates chronic otitis media. Interventions: avoid chewing during acute period, causes pain. local cold or heat and lie on affected ear down. clean drainage from outer ear. in healthy infants over 6 months and children, antibiotics recommended because concerns of drug-resistant streptococcus pneumoniae; usually wait 72 hours for resolution is a safe and appropriate management of acute otitis media. for ear meds in child younger than age 3 years, pull ear lobe down and back. in child older than 3 years, pull pinna up and back. Myringotomy: surgical incision into tympanic membrane for drainage of purulent middle ear fluid and may be done by laser assisted surgery.

Conjunctivitis

inflammation of conjunctiva also known as pink eye. by infection, allergy, or trauma. bacterial or viral conjunctivitis extremely contagious. Chlamydial conjunctivitis rare among older child; if diagnosed in child not sexually active, should be assessed for sexual abuse. Intervention: keep at home until antibiotics/ antibiotics eye drops given for 24 hours. avoid rubbing eye. stop wearing lenses until treatment complete and new lenses worn to avoid reinfection. eye makeup discarded and replaced with new makeup. use cool compress to lessen eye irritation and wear glasses for photophobia.after

Brain Tumors

infratentorial tumor, most common brain tumor, located in posterior third of brain. s/s depend on anatomical location, size, age of child. number of tests may be used in neurological evaluation, but most common diagnostic procedure is MRI, which determines location and extent of tumor. therapeutic management includes surgery, radiation, chemo. treatment of choice is total removal of tumor without residual neurological damage. Data collection: headache worse when awakening and improves during day. vomiting unrelated to feeding or eating. change in behavior. clumsiness; awkward gait or difficulty walking. facial weakness. diplopia(perception of 2 images of a single object). seizures. signs of ICP. (monitor for signs of ICP in child with brain tumor and after craniotomy) If signs of increased ICP, notify HCP. Preoperative interventions: monitor neurological status. institute seizure precautions and safety measures. monitor weight and nutritional status. child's head will be shaved (favorite hat/cap for child). shaving head may also be done in surgical suite. prep child as much as possible and tell child they will wake up with a large head dressing. Postoperative interventions: monitor neurological and motor function and LOC. monitor temperature because it may be elevated as result of hypothalamus or brainstem involvement during surgery; maintain cooling blanket by bedside. monitor signs of respiratory infection. monitor for signs of meningitis (opisthotonos, Kernig's and Brudzinski's signs). monitor for increased ICP or hemorrhage; check back of head dressing for pooling of blood; notify RN if signs of increased ICP or bleeding noted. monitor pupillary response; sluggish, dilated, or unequal pupils reported immediately because they may indicate increased ICP and potential brainstem herniation. monitor for colorless drainage on dressing or from ears or nose because it indicates cerebrospinal fluid and report immediately. Check for glucose in drainage (dipstick). check prescription for positioning, including degree of neck flexion. monitor IV fluids to prevent volume overload. prevent vomiting because this increases ICP and risk for incisional rupture. quiet environment. analgesics. emotional support and provide maximum functioning for child.

Diabetes Mellitus: insulin deficiency leading to ketoacidosis

insulin deficiency: impaired metabolism of fats, proteins, carbohydrates. Hyperglycemia: fatigue, hunger, weight loss. polyuria, cellular starvation. ketones, produced in response to cellular starvation, cannot nourish cell because of absence of insulin. Ketoacidosis.

Iron deficiency anemia

iron stores depleted, resulting in decreased supply of iron for the manufacture of hemoglobin in RBC. commonly results from blood loss, increased metabolic demand, syndromes of GI malabsorption, dietary inadequacy. Data collection: pallor, weak/fatigue, low hbg/hct, RBC are microcytic and hypochromic. Interventions: increase oral iron; iron fortified formula for infant. food choices high in iron. iron supplements. IM injection of iron (z track) or IV of iron if severe. How to administer iron supplements: give between meals for maximum absorption. with multivitamin or fruit juice because vitamin C increases absorption. dont give with milk or antacids because decreases absorption. teach side effects (black stool, constipation, foul aftertaste). keep med in safe place to avoid iron overdose. liquid iron stains teeth, so take with straw and brush teeth after administration.

3 week infant has a phenylketonuria rescreening blood test. Test indicates serum phenylalanine level of 0. Nurse reads this and makes what interpretation?

it is negative. phenylketonuria is a genetic (autosomal recessive) disorder that results in central nervous system damage from toxic levels of phenylalanine (an essential amino acid) in blood. characterized by blood phenylalanine levels greater than 20. normal level is 0-2. result of 0 is a negative test result.

Ingestions of poisons: Corrosives

items that can cause poisoning include household cleaners, detergents, bleach, paint or paint thinners, or batteries. liquid corrosives can cause more damage that other types such as granular. Interventions: dilute corrosive with water or milk, usually no more than 4 oz. induce vomiting contraindicated because vomiting redamages mucous membranes. Neutralization of ingested corrosive is not done because can cause reaction causing heat and burns teach parents to call poison control immediately in event of poisoning and before interventions. Post poison control number near each telephone in the house.

Celiac Disease

known as gluten enteropathy or celiac sprue. intolerance to gluten, the protein component of wheat, barley, rye, and oats, is characteristic. symptoms occur most often in ages 1-5 years. Interventions: gluten free diet and substitution of corn, rice, and millet as grain sources. lifelong elimination of gluten such as wheat, rye, oats, and barley. mineral and vitamin supplements, including iron, folic acid, and fat soluble supplements A, D, E, K. Foods allowed: beef, pork, poultry and fish, eggs, milk, dairy, vegetables, fruits, rice, corn, gluten free wheat flour, puffed rice, cornflakes, cornmeal, precooked gluten free cereals. Foods not allowed: commercially prepared ice cream, malted milk, prepared pudding, grains, anything made from wheat, rye, oats, barley, breads, rolls, cookies, cakes, crackers, cereal, spaghetti, macaroni noodles, beer, ale.

Blood lead level test results and intervention

less than 10: reassess or rescreen in 1 year or sooner if exposure status changes. 10-14: give family lead education, follow up testing, social service referral for home assessment if needed. 15-19: give family lead education, follow up testing, social service referral if needed. on follow up testing, initiate actions for blood lead level of 20-44. 20-44: coordination of care, clinical management, including treatment, environmental investigation, and lead hazard control. 45-69: coordination of care and clinical management within 48 hours, including treatment, environment investigation, and lead hazard control. child must not remain in lead hazardous environment if resolution necessary. more than or equal to 70: medical treatment immediately, including coordination of care, clinical management, environmental investigation, and lead hazard control.

child with pneumonia complains of pain in pleural area on affected side. What should nurse do?

lie on affected side if pneumonia is unilateral to splint the chest. this position reduces discomfort associated with pleural rubbing. mild analgesic may be prescribed.

child suddenly vomits, what should nurse do to prevent aspiration?

maintain patent airway. position upright or on side to prevent aspiration. suction equipment obtained and kept at bedside. check character and amount of vomitus. force of vomiting assessed because projectile vomiting can indicate pyloric stenosis or increased ICP. monitor I&O for signs of dehydration.

Leukemia

malignant increase in number of leukocytes, usually at immature stage, in bone marrow. proliferating immature WBC depress bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, bleeding from decreased platelet production (thrombocytopenia). cause unknown and involves genetic damage of cells, leading cells from normal state to a malignant state. Risk factors: genetic, viral, immunological, chemicals, meds. acute lymphocytic leukemia is most common cancer in children. more common in boys than girls after year 1. prognosis depends on age at diagnosis, initial WBC, type of cell involved, sex of child. treatment is chemo, radiation, hematopoietic stem cell transplantation. Data collection: infiltration of bone marrow causes fever, pallor, fatigue, anorexia, hemorrhage (usually petechiae), and bone marrow joint pain; pathological fractures can occur from bone marrow invasion with leukemic cells. infection from neutropenia. hepatosplenomegaly and lymphadenopathy. normal, elevated, or low WBC, depending on presence of infection, or of immature versus mature WBC. decreased hgb and hct and platelet. positive bone marrow biopsy identifying leukemic blast (immature) phase cells. signs of ICP from CNS involvement. sign of cranial nerve (cranial nerve VII or facial nerve most commonly affected) or spinal nerve involvement. s/s depend on area involved. s/s that indicate invasion of leukemic cells in kidneys, testes, prostate, ovaries, GI, and lungs. Infection: occur through self or cross contamination. common sites of infection are skin (any break in skin is potential sign of infection), respiratory or GI tract. Bleeding: platelet transfusions reserved for active bleeding that does not respond to local treatment and may occur during induction or relapse therapy. Packed RBC prescribed if severe blood loss. Fatigue and nutrition: assist in selecting well balanced diet. small meals that require little chewing and not irritating to oral mucosa. parenteral or enteral feeding if cannot take oral feedings. assist in self care and mobility activities. adequate rest periods during care. avoid nursing care activities unless essential.

Leukemia Chemotherapy

monitor for severe bone marrow suppression. during greatest bone marrow suppression (the nadir), blood counts will be extremely low. monitor for infection and bleeding. protect from life threatening infections. monitor for n/v, alterations in bowel function. stool softeners to prevent straining and bleeding if constipated. rectal hygiene gently as needed. antiemetics before chemo started. monitor for dehydration, hemorrhagic cystitis, peripheral neuropathy. check oral mucous membranes for mucositis. frequent mouth rinse to promote healing and prevent infection. local oral anesthetic may be prescribed. teach s/s to monitor after chemo and when to notify PHCP. hair loss can occur and regrow in 3-6 months and may be slightly different color and texture. teach about care of central venous access device. monitor closely for signs of infection because infection is a major cause of death in immunocompromised child.

Osteosarcoma (osteogenic sarcoma)

most common bone cancer in children. clinical manifestation is progressive , insidious, intermittent pain at tumor site. By the time these children receive medical intervention, they may be in considerable pain from tumor. Data collection: localized pain in affected site (severe or dull) that may be attributed to trauma or vague complaint of "growing pains". pain often relieved by flexed position. palpable mass. limping if weight bearing limb affected. progressively limited ROM; child curtails physical activity. unable to hold heavy objects because of weight and affected extremity. pathological fractures at tumor site.

Nephroblastoma (Wilms' Tumor)

most common intraabdominal and kidney tumor of childhood. unilaterally and localized, or bilaterally, sometimes with metastasis to other organs. Therapeutic management: combination of surgery (partial to total nephrectomy) and chemo with or without radiation, depending on clinical stage and histological pattern of tumor. Data collection: swelling or mass within abdomen; mass is firm, nontender, confined to one side, and deep within flank. Preoperative interventions: avoid palpation of abdomen; place sign at bedside that reads "do not palpate abdomen." Do not palpate abdomen and be cautious when bathing, moving, or handling child. keep incapsulated tumor intact. tumor rupture can cause cancer cells to spread throughout abdomen, lymph system, and bloodstream.

Epistaxis (nosebleeds)

nose, especially septum is highly vascular. recurrent epistaxis can mean underlying disease. intervention: if bleeding not controlled, packing or cauterizing blood vessel may be prescribed.

Priority nursing action Nosebleed in a child

nurse remains calm. assist to sitting up and leaning forward position to prevent aspiration of blood. DO NOT place in lying down position. nosebleeds usually are from anterior part of nasal septum and can be controlled by pressure on soft lower portion of nose with thumb and forefinger for 10 min. if bleeding persists, cotton or wadded tissue placed into each nostril and ice or cold cloth on nose bridge. if bleeding does persist, PHCP notified and nose packed by PHCP. after nosebleed stops, petroleum or water soluble jelly into each nostril to prevent crusting of old blood and lessen likelihood of child picking at crusting lesions and restarting bleeding. bleeding lasting longer than 30 min may need evaluation of bleeding disorder.

Abdominal Wall Defects: Omphalocele

occurs when herniation fo abdominal contents through umbilical ring (hernia of umbilical cord), usually with an intact peritoneal sac. immediately after birth, sac covered with sterile gauze soaked in NS to prevent drying of abdominal contents; layer of plastic wrap placed over gauze for protection against moisture loss. rupture of sac is from evisceration of abdominal contents. Once infant stabilized, synthetic material (Silastic) used to cover intestines. checking temp is important because can lose heat through sac. Preoperatively: maintain NPO. IV fluids for hydration and electrolyte balance. Monitor for infection and handle infant carefully to prevent rupture of sac.

Leukemia: protecting child from infection

protective isolation procedures. frequent and thorough hand washing. private room with high efficiency particulate air filtration or laminar airflow system. room cleaned daily. strict aseptic technique for all nursing procedures. limit number of caregivers entering room and wear mask. keep supplies separate from supplies from others. reduce exposure to environmental organisms by eliminating raw fruits/veggies and fresh flowers and not leaving standing water in room. daily bathing with antimicrobial soap. oral hygiene frequently. monitor s/s of infection. monitor oral/axillary temp, pulse, BP. change wound dressing daily and inspect wounds for redness, swelling, drainage. monitor urine for color and cloudiness. monitor skin and oral mucous membranes for infection. check lung sounds. cough and deep breathe. monitor WBC and neutrophil. notify RN if infection present and prep to obtain specimens for culture of open lesion, urine, sputum. bowel program to prevent constipation and rectal trauma. avoid invasive procedures such as injections, rectal temp, and urinary catheter. antibiotics, antifungal, antiviral meds. administer granulocyte colony-stimulating factor. keep away from crowds and those with infections. do not receive immunizations with live virus (measles, mumps, rubella, polio) because immune system is depressed and attenuated live virus can result in life threatening infection. child should not receive varicella vaccine. The Stalk (inactivated) vaccine for poliomyelitis can be given. parents should inform teacher that they should be notified immediately if case of a communicable disease occurs in in another child at school.

temp to avoid if diarrhea

rectal

nurse gave ibuprofen to child with temp of 102. The nurse should also take which action?

remove excess clothes and blankets from child. sponge with tepid water. aspirin not given to child if fever because of risk of Reye's syndrome. fluids encouraged to avoid dehydration.

Phenylketonuria (PKU) interventions

restrict phenylalanine intake. high protein (meat and dairy) and products that contain aspartame avoided because they contain large amounts of phenylketonuria. monitor physical, neurological, and intellectual development to detect abnormalities. follow up treatment important. educate about use of special preparation formulas and foods that contain phenylketonuria.

home care teaching for scabies

seal up all nonwashable toys in plastic bag for at least 4 days. everyone who has come in contact with my child needs to be treated for scabies. wash all clothing and bedding in hot water with detergent and dry in hot drier. applying scabicide to cool dry skin at least 30 min after bathing, which needs to be left on skin for 8-14 hours and then washed off.

Ingestions of poisons: Acetaminophen poisoning

seriousness determined by amount ingested and length of time before intervention.. toxic dose is 150 or higher in children. Data Collection: first 2-4 hours: malaise, n/v, sweating, pallor, and weak. latent period: 24-36 hours; child improves. hepatic involvement: may last 7 days and be permanent; right upper quadrant pain, jaundice, confusion, stupor, elevated liver enzymes and bilirubin levels, and prolonged prothrombin time. Intervention: antidote N-acetylcysteine. antidote diluted in juice or soda from offensive odor. loading dose followed by maintenance doses. if child unconscious, prep gastric lavage with activated charcoal to decrease absorption of acetaminophen. if using activated charcoal with lavage, do not also use N-acetylcysteine because activated charcoal will inactivate antidote.

list for home care on patient with pediculosis capitis

siblings may also need treatment. grooming items such as combs and brushes should not be shared. launder all bedding and clothing in hot water and dry on high heat. vacuum floors, play areas, and furniture to remove any hairs that may carry lice. antilice sprays non necessary.

18 month vomiting. what position to place for naps and sleep time?

side lying position.

Sickle Cell Anemia

situations that precipitate sickling: fever, dehydration, emotional or physical stress; any condition that increases need for oxygen or alters transport of oxygen can result in sickle cell crisis (acute exacerbation). Hemoglobin S is sensitive to changes in oxygen content of RBC. interprofessional approach to care is needed, and care focuses on prevention (preventing exposure to infection and maintaining normal hydration) and treatment (hydration, oxygen, pain management, and bedrest) of the crisis. Intervention: maintain hydration and blood flow with oral and IV fluids. Electrolyte replacement. without hydration, pain will not be controlled. oxygen to increase tissue perfusion. blood transfusions. analgesics around the clock. assist in comfortable position to keep extremities extended to promote venous return. elevate head of bed no more than 30 degrees. avoid putting strain on painful joints. do not raise knee gatch of bed. high calorie, high protein, and folic acid supplements. antibiotics to prevent infection. monitor complications of increasing anemia, decreased perfusion, and shock (mental changes, pallor and vital sign changes). teach early signs and symptoms of crisis and prevention. strict adherence to immunization schedules. make sure receives pneumococcal and meningococcal vaccines and annual influenza vaccine because of susceptibility to infection from functional asplenia. splenectomy if experiencing recurrent splenic sequestration. inform parents of hereditary aspects of disorder. meperidine for pain is avoided because of risk of normeperidine-induced seizures.

Major burn injury in child

stop burning process. check circulation, airway, and breathing status. begin resuscitation if necessary. remove burned clothes and jewelry. cover wound with clean cloth. keep child warm. transport to emergency department.

How to prevent spread of impetigo?

strict contact precautions and use standard precautions. isolation procedures for hospitalized child. strict hygiene because it is highly contagious. make sure all HC workers and visitors are aware to prevent spread of infection.

Atopic Dermatitis (Eczema)

superficial inflammatory process that primarily involves epidermis and characterized by pruritic lesions. associated with family history of the disorder, allergies, asthma, or allergic rhinitis. Major goals of management are to relieve pruritus, lubricate skin, reduce inflammation, and prevent or control secondary infections. Interventions: avoid skin irritants (soap, detergent, fabric softener, diaper wipes, powder). avoid excess bathing and washing area. bathing water should be tepid and skin lubricated right after. intermittently apply cool, wet compress for short periods to soothe skin and alleviate itch; pat skin dry between cooling treatments. antihistamines and corticosteroids applied in thin layer and rubbed into area thoroughly. antibiotics if secondary infections occur. prevent or minimize scratching. keep nails short and clean and place gloves or cotton socks over hands. eliminate conditions that increase itching (wet diapers, excess bathing, ambient heat, woolen clothes or blankets, rough fabrics, furry stuffed animals). exposure to latex avoided. wash child clothing in mild detergent and rinse thoroughly. put clothes through second complete wash cycle without detergent will minimize residue remaining. measures to prevent skin infections. monitor lesions for signs of infection (honey colored crusts with surrounding erythema) and seek medical intervention if signs noted. child with integumentary disorder needs to be monitored for either a skin infection or systemic infection.

Appendectomy

surgical removal of appendix. Preoperative interventions: initiate IV line, NPO, IV antibiotics, preop meds. NPO, IV fluids and electrolytes. monitor for ruptured appendix and peritonitis. pain meds may be avoided to not mask pain changes associated with perforation. position on right side lying or low to semi fowler. avoid applying heat to abdomen and administering laxatives or enemas because of risk of perforation. Postoperative interventions: maintain NPO until bowels return. position in right side lying or low to semi fowler with legs slightly flexed to facilitate drainage.

Intussusception

telescoping of one portion of bowel into another. results in obstruction of passage of intestinal contents. Data collection: currant jelly like stools that contain blood and mucus. tender and distended abdomen, possibly with palpable sausage shaped mass in upper right quadrant. Interventions: monitor for signs of perforation and shock from fever, increased HR, change in LOC or BP, and respiratory distress, and report immediately. monitor for passage of normal, brown stool, which indicates intussusception has reduced itself. prep for hydrostatic reduction if no signs of shock or perforation occur(air/fluid exerts pressure of area involved to lessen, diminish, or rid intestine of prolapse).

Hyperglycemia interventions

tell parents to notify PHCP when: BG remain elevated, usually above 200. moderate or high ketonuria present. unable to take food or fluids. vomits more than once. illness persists.

how to care fo child with hemophilia who was in a motor vehicle accident?

they are at risk for bleeding. place on bleeding precautions and monitor for bleeding. this is a priority intervention. monitor vitals and joint pain. joint bleeding controlled by immobilization, elevation, and ice application. pressure applied for 15 min for any superficial bleeding. neurological status checked because at risk for intracranial hemorrhage. monitor urine for hematuria. blood replacement may be prescribed.

Tonsilitis and Adenoiditis

tonsilitis: inflammation and infection of tonsils, which is lymphoid tissue in the pharynx. adenoiditis: inflammation and infection of adenoids (pharyngeal tonsils), on posterior wall of nasopharynx. tonsillectomy: removal of tonsils. adenoidectomy: removal of adenoids. data collection: mouth breathing and bad breath. enlarged adenoids can cause nasal quality of speech, mouth breathing, hearing difficulty, snoring, obstructive sleep apnea. pre-op interventions: monitor bleeding and clotting studies because throat very vascular. check for loose teeth to not aspirate. post-op interventions: position child prone or side lying to facilitate drainage. suction equipment ready in case of airway obstruction. no cough, clear throat, or nose blowing to prevent bleeding. ice collar or analgesics. clear, cool, noncitrus, and noncarbonated fluids. crushed ice or ice pops. avoid red, purple, or brown liquids because it will look like blood if child vomits. avoid milk, such as milk, ice cream, and pudding initially because they will coat throat, causing child to clear throat. soft foods 1-2 days post op. no straws, forks, or sharp objects that can be put in mouth. bad breath, slight ear pain, low grade fever normal, but report to PHCP if bleeding and persistent earache or fever occurs. stay away from crowds until healed. resume normal activities after 1-2 weeks post op.

Priority Nursing Actions: Poisoning treatment in emergency department

treat child first, not the poison. ABC's (airway, breathing, and circulation) and vitals assessed. CPR if necessary. exposure to poison terminated next, such as emptying mouth of pills or other materials or flushing skin or other body area with water. then, poison identified by questioning parents or witnesses to determine treatment. nurse gives antidote or takes measures prescribed by PHCP such as giving activated charcoal. document occurrence, assessment of findings, poison ingested, treatment measures, and child response.

Diabetes mellitus

type 1: destruction of pancreatic beta cells, which produce insulin. Results in absolute insulin deficiency. type 2: usually arises as a result of insulin resistance, body fails to use insulin properly, in combination with relative, rather than absolute, insulin deficiency. insulin deficiency requires exogenous insulin to promote appropriate glucose use and prevent complications related to elevated BG such as hyperglycemia, diabetic ketoacidosis, and death. Diagnosis based on classic symptoms and elevated BG (normally 70-110). children may be admitted directly to pediatric ICU because of manifestations of diabetic ketoacidosis which may be initial occurrence when diagnosed with diabetes mellitus.

Hodgkin's Disease

type of lymphoma. malignancy of lymph nodes that originates in single lymph node or single chain of nodes. characterized by presence of Reed-Sternberg cells in lymph nodes. Data collection: painless enlargement of lymph nodes. enlarged, firm, nontender, movable nodes in supraclavicular area. sentinel node located near left clavicle may be the first enlarged node. nonproductive cough from mediastinal lymphadenopathy. abdominal pain from enlarged retroperitoneal nodes. advanced lymph node and extralymphatic involvement can cause systemic symptoms such as low grade and/or intermittent fever, anorexia, nausea, weight loss, night sweats, pruritus. positive biopsy of lymph node (presence of Reed-Sternberg cells) and positive bone marrow biopsy specimen. CT scan of liver, spleen, and bone marrow to detect metastasis. Interventions: for early stages without mediastinal node, extensive external radiation of involved lymph node regions. with more extensive disease, radiation combined with multiagent chemo. monitor for drug induced pancytopenia and abnormal depression of all cellular components of blood, which increases risk of infection, bleeding, and anemia. protect from infection. safe, hazard free environment. monitor adverse effects related to chemo or radiation. most common side effect of extensive irradiation is malaise, which can be difficult for older children and adolescents to tolerate physically and psychologically. monitor for n/v and administer antiemetics.

Bronchitis

usually associated with upper respiratory infection. causative agent most often viral. Data collection: fever and non productive cough worse at night and becomes productive in 2-3 days. Interventions: monitor for respiratory distress. cool humidified air. increased fluid intake. may drink beverages that they like as long as the respiratory status is stable. antipyretics for fever. meds to provide rest

Burned Child Pediatric differences

very young children who have been severely burned have a higher mortality rate than older children and adults with comparable burns. lower burn temp and shorter exposure to heat can cause more severe burn in child than adult because child skin is thinner. degree of pain by child and ability to communicate it will be different that in an adult with same exposure. severely burned child is at increased risk of fluid and heat loss, dehydration, and metabolic acidosis than an adult. the higher proportion of body fluid to body mass in child increases risk of cardiovascular problems. burns involving more than 10% of body surface area requires form of fluid resuscitation. infants and children are at higher risk of protein and calorie deficiency because they have smaller muscle mass and less body fat than adults. scarring more severe in child, so disturbed body image will be distinct issue for child or adolescent, especially as growth continues. immature immune system presents to increased risk of infection for infants and young children. delay in growth may occur following burn. in pediatric client, the extent of burn is expressed as percentage of total body surface area (TBSA) using specific age related charts. Fluid replacement therapy: to determine adequacy of fluid resuscitation, vital signs (especially HR), urine output, adequacy of capillary filling, and sensorium status are assessed. necessary during initial 24 hour period following burn injury because of the fluid shifts that occur as result of the injury. formulas used to calculate fluid needs, but it depends on HCP preference. Crystalloid solutions used during initial phase of therapy; colloid solutions such as albumin, Plasma-Lyte (combined electrolyte solution), of fresh frozen plasma useful in maintaining plasma volume.

laryngotracheobronchitis (Croup)

viral or bacterial and most frequent in child younger than 5 years. Data Collection: Stage 1: low grade fever, hoarseness, seal bark and brassy cough(croup cough), inspiratory stridor, fear, irritability and restless. stage 2: continuous respiratory stridor, retractions, use accessory muscles, crackles and wheezing, labored respirations. stage 3: continued restless, anxiety, pallor, diaphoresis, tachypnea, signs of anoxia and hypercapnia. Stage 5: intermittent cyanosis that progresses to permanent cyanosis, apneic episodes that progress to cessation of breathing. Interventions: maintain patent airway. monitor respiratory status and pulse ox; check nasal flare, sternal retractions, and inspiratory stridor. monitor for respiratory exchange; monitor pallor and cyanosis. elevate head of bed and provide rest. humidified oxygen via cool mist tent for hospitalized child. at home use cool air vaporizer or humidifier or have child breathe in cool night air or air from open freezer and taking to cool basement or garage. encourage fluids, IV fluids if unable to take oral fluids. analgesics to reduce fever. avoid cough syrups and cold meds because they can dry and thicken secretions. corticosteroids for inflammation. nebulized epinephrine(racemic epinephrine) for child with severe disease experiencing stridor at rest, retractions, or difficulty breathing. antibiotics not indicated unless bacterial infection present. Heliox (mixture of helium and oxygen) reduces work of breathing, reduces airway turbulence, and helps relieve obstruction. have resuscitation equipment available. reassurance and education to parents or caregivers. during croup attack, take to cool basement or garage. acetaminophen if fever develops. hydration of 500-1000 mL of daily fluids to thin secretions. Isolation precautions for child in hospital with upper respiratory infection until cause of infection known. if acute spasmodic episode occurs: steam from warm running water in closed bathroom and cool mist from bedside humidifier are effective for reducing mucosal edema. cool mist humidifiers recommended compared to steam vaporizers which present danger of scalding burns. taking out to humid night can also relieve mucosal swelling. cold mist precipitates bronchospasm.

Appendicitis

when appendix becomes inflamed or infected, perforation may occur within a matter of hours, leading to peritonitis(inflammation of peritoneum), sepsis, septic shock, and potential death. treatment is removal of appendix before perforation occurs. Data collection: abdominal pain most intense at McBurney's point. pain in periumbilical area that descends to right lower quadrant. referred pain meaning peritoneal irritation. elevated WBC. side lying position with abdominal guarding with legs flexed to relieve pain. difficulty walking and pain in right hip. Peritonitis: from perforated appendix. Data collection: increased fever. progressive abdominal distention. tachycardia and tachypnea. pallor. chills. restless and irritability. indicator of perforated appendix is sudden relief of pain and then a subsequent increase in pain accompanied by right guarding of the abdomen.

What to do if sick child who has type 1 diabetes mellitus at home has ketones in urine?

when child is sick, mom should test ketones with each voiding. if ketones present, liquids are essential for clearing ketones and encouraged to drink liquids. bringing to clinic is unnecessary and insulin doses should not be adjusted or changed.

positive head check of lice

white sacs attached to hair shafts in occipital area.