Peds. Exam
A 7-year-old child is brought to the clinic by a parent for a school physical. When the child is prepared for examination, which of the following interventions should the nurse provide to ensure the child's comfort?
Explain the purpose of the equipment being used during the examination
Patent Ductus Arteriosus
Failure of the fetal ductus arteriosus (artery connecting the aorta and pulmonary artery) to close within the first weeks of life • Closure is complete by 7-14 days of life; full closure may not occur until 3 months of life o May take longer in infants with family history of it or lung disease
Chief C/O for Rheumatic Fever
Fever, Joint Pain, and Rash
Aortic Stenosis
Stenosis or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion
Kawasaki S/S
Strawberry tongue, fever unresponsive to meds., red lips and eyes, rash, edema, peeling of hands and feet.
Rhematic fever follows what infection?
Streptococcal Pharyngeal Infection
Four Anomalies
Tetralogy of Fallot- VSD, Pulmonic Stenosis, Overriding Aorta, Right Ventricular Hypertrophy
Transposition of the Great Arteries
The aorta arises from the right ventricle instead of the left, and the pulmonary artery arises from the left ventricle instead of the right with no communication between the systemic and pulmonary circulations
A school-age child is being discharged with a diagnosis of rheumatic fever. Which instructions should be included in the teaching plan for the family?
The child should stay on penicillin and return for a follow-up appointment.
A preschool-age child with sickle cell anemia is admitted to the health care facility in vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's highest priority when caring for this child?
provinding fluids
Nursing care to decrease cardiac demand:
quiet room, sit them up, cluster care, prevent crying, sedate irritable child.
A nurse is planning care for a 10-year-old child in the acute phase of rheumatic fever. Which activity is most appropriate for the nurse to schedule in the care plan?
reading books
Prevent bleeding for hemophilia:
safe environment, helmets, carpet in home, pad sharp corners, PT to strengthen joints and muscles, no contact sports, avoid ATVs and trampolines.
Ways to decrease energy spent for an infant with CHF:
small frequent meals no more than 20 mins., NG tube to bolus feed will decrease energy use. High flow nipple to eat faster.
Which sign is an early indicator of heart failure in an infant with a congenital heart defect?
tachycardia
Prevent vasoocclusive crisis event in sickle cell:
treat fever immediately, adequate fluids, avoid extreme temperatures and stress.
When teaching the parents of a child diagnosed with tetralogy of Fallot about the cardiac defects involved with this condition, which defects should the nurse describe? Select all that apply.
ventricular septal defect, overriding aorta, right ventricular hypertrophy, and pulmonary stenosis
When teaching school-age children important injury prevention strategies, the nurse must use creativity to gain cooperation because children tend not to comply with:
wearing safety apparel (helmets, knee pads, elbow pads).
PDA Dx.
• Diagnosed with echocardiogram - good visualization of PDA
Tetralogy of Fallot
• Four anomalies à what make up tetralogy of fallot o Pulmonary stenosis o Ventricular septal defect o Dextroposition of aorta (overriding of aorta) o Hypertrophy of the right ventricle
A nurse is caring for a 9-year-old child who is scheduled for surgery. The parents ask the nurse not to tell the child about the surgery until leaving for the operating room. Which response best demonstrates the nurse's role in supporting the child's rights?
"It is important to tell your child about the surgery in order to allow time for any questions to be answered."
A nurse is teaching the parents of an infant with heart failure about the administration of furosemide. The parents will be administering the medication to the infant at home. What is the most important information for the nurse to teach the parents about the drug administration?
"It's important to call the clinic if there is no urine output in 8 hours."
A nurse is providing injury-prevention education to the parents of a school-aged child. The parents admit that they keep a gun in their home. Which of the nurse's statements is most appropriate?
"The gun should be stored unloaded in a locked cabinet."
A nurse has just received a report from the nurse who worked the previous shift. Which child should she assess first?
A 6-year-old child with acute heart failure on 2 L of oxygen. (VS: A 5-year-old child who needs factor VIII before a tonsillectomy. A 4-year-old child admitted with reactive airway disease receiving albuterol every 4 hours. A 3-year-old child who had an appendectomy and is complaining of pain.)
VSD
Abnormal opening between the right and left ventricles
Atrial Septal Defect
Abnormal opening between the two atria, allowing blood from the higher pressure left atrium to flow into the lower pressure right atrium
Nursing Dx. HF
Activity Intolerance, Impaired Gas Exchange, Fluid Volume Excess, Ineffective Breathing Pattern, Decreased CO
Narrowing stricture of the aortic valve:
Aortic Stenosis
Digoxin Administration
Apical pulse 1 minute prior to administration- not rate, rhythm, and quality.
The nurse is caring for an infant diagnosed with a congenital heart disease. Which of the following concerns should be a priority for the nurse to address with the parents when discussing the child's condition?
CHF
Localized narrowing of the aorta.
Coarctation of the Aorta
Kawasaki 2nd Dose of IV Ig within 1st 10 days?
If continues to have prolonged fever > 10 days- yes. Give 2nd dose.
The nurse is planning care with the parents of a 4-month-old infant with heart failure and congenital heart disease. The parents report that their child tires easily. Which intervention is a priority for this child?
Increase the number of rest periods.
Erikson Stage of Psychosocial Development
Industry vs. Inferiority
When assessing a child with hemophilia, the nurse identifies which condition as an early sign of hemarthrosis?
Joint Stiffness
IV Ig Administration
Kawasaki Disease: 8-10 Hours. IV Ig- monitor like blood product. VS's. For immune deficiency 4-8 hours.
Prostaglandin E1
Keeps ductu arteriosus open, oxygenated blood to mix and get into system.
Coarctation of the Aorta
Localized narrowing near the insertion of the ductus arteriosus, which results in increased pressure proximal to the defect (head and upper extremities) and decreased pressure distal to the obstruction (body and lower extremities)
Coarctation of Aorta S/S
Lower Extremities: cold, pallor, decreased BP, weak pulses. Upper Extremities: increased BP, bounding pulses.
Pulmonary Stenosis
Narrowing of the pulmonary valve or pulmonary artery
Age group abstract thinkers?
Not at 1st- they will grow to be logical thinkers.
S/S of CHF
SOB, Edema, Poor Feeding, Tachypnea, Retractions, Fatigue, Sweating, Prevent Cold Stress
A school-age child is admitted to the hospital in vasoocclusive sickle cell crisis. Place the prescriptions in the order of priority (first to last) that the nurse should implement them. All options must be used.
Start oxygen via nasal cannula. Start an intravenous infusion. Administer morphine for the pain. Draw blood for electrolyte levels and pH balance.
The pulmonary artery leaves the left ventricle and the aorta leaves the right ventricle.
Transportation of the Great Vessels
Opening between the ventricles:
VSD
Can Rheumatic Fever reoccur?
Yes
Is successful play necessary to build positive self image?
Yes
A young child with sickle cell anemia prefers a side-lying position with the knees sharply flexed. The nurse should assess further for:
abd. pain
Which intervention is the greatest priority for the therapeutic management of a child with congestive heart failure (CHF) resulting from pulmonary stenosis?
administering furosemide to decrease systemic venous congestion
Which action should a nurse include in the care plan for a 2-month-old infant with heart failure?
allow the infant to rest before feeding
A physician orders digoxin elixir for a toddler with heart failure. Immediately before administering this drug, the nurse must check the toddler's:
apical pulse
Pain management of vasoocclusive crisis:
assess, believe child, opioid 8-10, or NSAID. Monitor complications, give IF fluids, and provide quiet restful environment.
A nurse is giving instructions to parents of a school-age child diagnosed with sickle cell anemia. The instructions should include:
avoiding areas of low oxygen concentration such as high altitudes.
S/S of hemophilia:
bleeding, joint deformities, bruising, epistaxis, hemorrhage into joints and muscles.
A toddler with a ventricular septal defect is receiving digoxin to treat heart failure. Which assessment finding should be the nurse's priority concern?
bradycardia
A child, age 4, is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a bounding radial pulse coupled with a weak femoral pulse, the nurse suspects that the child has:
coarctation of the aorta
A mother is concerned about her 9-year-old child's compulsion for collecting things. The nurse's explanation is based on the understanding that this behavior is related to the cognitive ability to perform which functions?
concrete operations
A child, age 6, is anxious and upset before a scheduled bone marrow aspiration. During client preparation, the nurse should keep in mind that:
describing what the child will hear, see, smell, and feel will help the child cope with the procedure.
When teaching a group of parents of school-age children about growth and development, which characteristic about children of this age should the nurse include?
desire to carry a task to completion
The nurse is caring for a child with hemophilia who is actively bleeding from the leg. The nurse should apply:
direct pressure to the injured area continuously for 10 minutes.
A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions for avoiding future crises would the nurse provide to the child and family? Select all that apply.
drink plenty of fluids, report a sore throat to an adult immediately, and wash hands before meals and after playing
To assess a 9-year-old's social development, the nurse asks the parent if the child:
has a best friend
A nurse is assessing the growth and development of a 10-year-old. What is the expected behavior of this child?
has a strong sense of justice and fair play
School age vulnerable for dental carries:
inadequate dental care since they do it themselves.
When developing a plan of care with a mother who expresses concern that her 10-year-old son is overweight, the nurse should expect to include which intervention?
including the child in meal planning and preparation
Which assessment finding is an early sign of heart failure in a toddler?
increased RR
The nurse is conducting health assessments for school-age children. A characteristic behavior of a 7-year-old girl is that she:
likes to play only with other girls.
Hemophilia parent education:
no contact sports, helmets, injury prevention, know how to administer clotting factors.
VSD Tx.
o 85% of VSDs will close on their own o Diuretic and digoxin to help prevent fluid accumulating in the lungs • Watch for toxicity - N/V, bradycardia, anorexia, and dysrhythmias o Closure can be accomplished by septal occluder that can be placed in heart catheterization to close off VSD or cardiac patch o Monitor postoperatively for arrythmias - at risk due to surgery • Cause in inflammation/edema on right side of heart • Conduction might interfere with the AV node
PDA CM
o A characteristic machinery-like murmur
AS Patho.
o A stricture in the aortic outflow tract causes resistance to ejection of blood from the left ventricle • The extra workload on the left ventricle causes hypertrophy o If left ventricular failure develops, left atrial pressure will increase; this causes increased pressure in the pulmonary veins, which results in pulmonary vascular congestion (pulmonary edema)
PDA Patho.
o Blood will shunt from the aorta across the duct to the pulmonary artery o The additional blood is recirculated through the lungs and returned to the left atrium and left ventricle causing: • Increased workload on the left side of the heart • Increased pulmonary vascular congestion and possibly resistance • Potentially increased right ventricular pressure and hypertrophy • Keeps blood from being fully circulated throughout the body
TOF Dx.
o Cardiac cath to visualize all of the defect o Echo shows pulmonary stenosis and hypertrophy in the right ventricle
VSD Dx.
o Chest X-ray o ECG o Echocardiography & MRI • Will see larger right ventricle and there might be dilation of pulmonary artery from increased pressure and blood flow
Patho.
o Closed circuit that is incompatible with life o In order for it to support life, have to have ASD, VSD, or PDA is needed to promote systemic blood flow or the pulmonary circulation for mixing of saturated and desaturated blood
TOF Tx.
o Decrease hypercyanotic episodes o Propranolol (Inderal) o Oxygen o Morphine sulfate to increase pulmonary artery dilation o Full surgical repair can be done and without complications can have a normal life - advantage o Teach parents - keep knee to chest position because it keeps blood in lower extremities and from flowing back in • Hopefully helps them from having hyper-cyanotic episodes
AS Dx.
o Echocardiogram and ECG to detect left ventricular hypertrophy
PS Dx.
o Echocardiography and ECG show right ventricle hypertrophy
ASD CM
o Harsh systolic murmur heart over 2nd-3rd intercostal space
ASD Patho
o Increased pulmonary blood flow to right side of heart o Right atrial and ventricular hypertrophy o Results in a right to left shunt o Results in cyanosis from decreased oxygen in the blood
ASD Diagnostics
o Increased pulmonary ciculation on echocardiogram • Viual opening between two openings
PS CM
o Infants may exhibit signs of mild right-sided HF • Enlarged liver and spleen • Occasional edema • Typically, in children you don't see one sided heart failure because they are codependent • May start out with symptoms on one side and if they persist or are not corrected, you will see both right and left sided HF o If narrowing is severe cyanosis may be present o Systolic ejection murmur at the upper left sternal border may be present o Second heart sound is usually widely spit
Coarctation Tx.
o Intervention angiography using a balloon catheter to open it up o Surgery removes the narrowed portion of the aorta and re-anastomose back • Children should achieve the greatest part of their height before they have surgery because it can affect growth and cause straining on the incision o Digoxin and diuretics for management o ACEI and beta blockers for postop hypertension
PS Tx.
o Management depends on severity of the stenosis o Balloon angioplasty through cardiac catheterization • If unable to correct this way, then can also replace valve (valvuloplasty)
TOF CM
o May not immediately have cyanosis after birth o As they become active, they show signs of cyanosis • The more active they are, the bluer they get o Will hear loud harsh murmur (most cases) or soft scratchy localized murmur o Polycythemia will develop o Severe dyspnea o Growth restriction o Clubbing of fingers o Position of comfort is knees to chest or squatting position o Tet syncope spells - acute episodes of cyanosis and hypoxia • occur when the infant's oxygen requirements exceed the blood supply, usually during crying or after feeding • Become cyanotic and hands, feet, and mouth turn blue • Monitor because at increased risk for emboli, seizures, LOC, or sudden death • Can happen with any heart defect that includes obstruction to pulmonary blood flow or any communication between the ventricles • Place infant in knee/chest position • Administer 100% blow by oxygen • IV or subQ morphine
Coarctation Patho.
o Narrowing of the lumen of the aorta due to a constricting band so smaller area within the aorta o Pressure building up before and decreased pressure after so the blood going out to the rest of body doesn't have enough pressure behind it
VSD Patho.
o Opening in the septum allows blood from the left ventricle to flow back into the pulmonary artery and right ventricle causing... • Right ventricular hypertrophy because of backflow into this chamber and its working harder to pump against resistance • Increased pressure in the pulmonary artery o Impairs the efficiency of the heart because blood that should be out in the body is flowing back into the heart
PS Patho.
o Right ventricle cannot expel blood resulting in hypertrophy of right ventricle o If right ventricle fails, right atrial pressure will increase, and this may result in: • Reopening of the foramen ovale • Shunting of unoxygenated blood into the left atrium • Systemic cyanosis o Eventually whole heart fails
AS Tx.
o Stabilization with beta-blocker or calcium channel blocker to reduce ventricular hypertrophy o Digoxin and diuretics o Surgical - balloon valvuloplasty or homograph valve through cardiac catheterization (both) • If use prosthetic valve, the patient has to be on heparin to prevent clots around the valve
ASD Tx.
o Surgery between ages 1-3 o Septal occluter or cardiac patch if it's a larger whole o Anytime you do surgery on the heart you have an increased risk for arrhythmias • Surgery on the right side causes SA node dysfunction so you'll have conduction problems • Monitor for arrythmias
AS CM
o Systolic murmur o Decreased cardiac output à faint pulses, hypotension, tachycardia, and inability to suck for long periods of time so will be poor feeders and will usually end up with a feeding tube o Chest pains when active - usually in older children o Pulmonary vascular congestion à back up in lungs, fluid in lungs
Coarctation CM
o Will have difference in BP from upper extremities to lower extremities • Ex: 20-30 mm Hg higher in left arm than left leg o Bounding arm pulses o Weak or absent femoral pulses o Cool lower extremities o Collateral circulation may develop and enlarged arteries may be seen on the ribs as obvious nodules • Really visible blue veins on the torso bypassing the narrowing of the aorta o Signs of HF in infants o Older children may experience dizziness, headaches, fainting, and epistaxis resulting from hypertension
PDA Tx.
o Will try medical management first • IV indomethacin or ibuprofen (DOC) to close • Even though ibuprofen is not recommended until 6 months of age, it will still be used because of less side effects than indomethacin; if still doesn't work will place a clip in o Ductal ligation in infants via thoracotomy o If still open at 6 months to 1 year of age can have interventional cardiac catheterization to place coil o If closure does not occur infant is at risk for CHF
VSD CM
o Won't see effects right at birth but will start to see symptoms at about 4-6 weeks of age when shunting begins o Infant may exhibit easy fatigue o Loud harsh systolic murmur heard at left sternal boarder at third or fourth interspace o A thrill may be present
The mother of an infant with hemophilia tells the nurse that she is planning to do home teaching when the child reaches school age. She does not want her child in school because the teacher will not watch the child as well as she would. The mother's comments represent what common parental reaction to a child's chronic illness?
overprotection
Safety teaching:
pedestrian car safety in and out of car, sports and cooking safety, water safety, and gun safety.
A child diagnosed with tetralogy of Fallot becomes upset, cries, and thrashes around when a blood specimen is obtained. The child becomes cyanotic and the respiratory rate increases to 44 breaths/min. Which action should the nurse do first?
place the child in a knee- to- chest position
The nurse is planning interventions for a school-aged child hospitalized with acute poststreptococcal glomerulonephritis in need of diversional activity. Which activity should the nurse expect to include?
playing a card game with someone the same age
Primary goal for Hemophilia:
prevent bleeding.
Sickle Cell disease goal:
prevent infection and crisis.
