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Pediatrics final exam

Terms in this set (314)

the continuum
community, culture, and family
who is the pt in pediatrics
the pt and the family
the nurses role in pediatrics
caregiver, educator, advocate, case manager
philosophy of care for the child
family centered

culturally sensitive

atraumatic
WHO 3 facets
anticipatory guidance

health promotion

health maintenance
pediatric physician visits
o One month, 2 month, 4 month, 6 month, 9 months 1 year, 15 month, 18 month, 2 years, and then every year
leading cause of hospitilization
respiratory causes
injury trends
o Less than 1
- suffocating (accidental)
- MVA

o 1-4
- Drowning
- MVA
- Fire/burns

o 5-9
- MVA
- Drowning

o 10-14
- MVA

o 15-19
- MVA
- Poisoning - suicides?
atraumatic care
Caring for patients in a manner in which all physiologic and psychological stressors are reduced as much as possible

ALWAYS FIRST DO NO HARM
· Prevent separation from family if you can incorporate family please do so
· Promote a sense of control do you want the shot on the left arm or the right arm?
· Prevent injury or pain numb them for lumbar puncture
PLAY
Occurs at every age

Physical, cognitive, and psych development

Nursing role: facilitate play

Gives child choice of sense of control, safety and security

Fosters growth and development

Provides stress relief

Distraction

Alleviates separation anxiety

Allows child to act out fears and concerns
child abuse red flags
If a child doesn't cruise, they shouldn't bruise

Bruises on torso, ears, neck

Bruises of various stages
concern with shaken baby syndrome
retinal hemorrhages

shearing - bleeding
toddler assessment
· Stranger anxiety use mom and dad
· Ignore them
· Avoid eye contact
· Offer a toy
· Listen to chest first before screaming
school age assessment
· 2-5 years
-May be a bit worried of stanger still

· 5-10
- Often less anxious
- Compliant with examination
-Ask the and if they say no explain why
teenager assessment
· Be professional
· Offer to see them alone
· Direct questions to pt
· Ask before doing anything
· Consent
· Discuss what they want
infancy introduction
Look at nonverbal behaviors and listen to vocalizations

Watch your own nonverbal cues
early childhood introduction
- Children <5 are egocentric

- Focus your communication on them

- Empathy is not in their vocab

- Let them play

- They will take things literally
school age introduction
Want explanations and reasons

Want to know steps of procedures

Concerned with body integrity

Have them vocalize fears
adolescent introduction
Fluctuate between child and adult like thinking

Privacy an issue

Interview without parents if possible
NIPS pain scale
neonatal infant pain scale

up to 6 weeks of age
FLACC pain scale
face, legs, activity, cry, consolable
faces scale
used for 3 years and older
oucher pain scale
real Facial pictures for kids.
children: head anatomy
Fontanela posterior closes and then anterior closes

Nose breathers until 5-6 months (stuffy nose as child - suction)

Myelination occurring

Large head compared to rest of body

Thin skull - fractures easy
children: CNS
Immature

Primitive reflexes present

Temperature regulation not stable
children: cardio
Less blood volume

Higher metabolic rate and heart rate
· Dehydration causes many more problems

CO, BP less than adult

Extremely vulnerable to volume loss
children: respiratory
More cartilage in ribs

Faster RR

Intercostal muscles not fully developed

Irregular, abdominal breathing in infants

Limited chest volume = limited reserve

Trachea smaller and easily irritates
· Choking and aspiration
children: GI
Immature

Infants tend to swallow air

Esophageal incoordination spit up from formula

Reflux

Decreased motility

Abdomen offers poor protection to liver and spleen

Liver immature

Limited stores of glycogen in liver may lead to hypoglycemia
Children: urinary
Kidneys immature

Until 12-18 months do not concentrate urine well

Absorption of electrolytes immature

Vulnerable to dehydration and overhydration

Drug toxicity
weight
Less than or equal to 5th = underweight

Greater than or equal to 85th or less than 95th = overweight

Greater than 95th = obese
birth weight doubles when
6 moths of age

1.5 pound/month for first 5 months
birth weight triples at
1 year of age
weight quadruples at
2 years of age
head circumference growth
1.5 cm/month

by 1 year HC increased by 33%
binocularity
fusion of 2 images
begins at 6 weeks and is developed at 4 months of age
fetal hemoglobin
present until 5 months of age

maternal iron stores depleted after 4 months
newborn immune system
Passive immunity (maternal igG until about 3 months

40% adult levels of IgG by age 1 year

Production of IgA, IgD, and IgE more gradual and not attained completely until early childhood (6 years old)
how much formula or breast milk every 2-3 hours for a newborn?
2-3 oz
car seat recommendations
· Infants and toddlers: rear facing

Toddlers/preschoolers: convertible seats with forward facing with harness

· School aged children: booster seats

· Older children: seat belts
Glabellar reflex
tap on the bridge of the infant's nose, infant should close eyes tightly
rooting reflex
a baby's tendency, when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple
extrusion reflex
Thrusting tongue movements that automatically push food out of the mouth
Moro reflex
Infant reflex where a baby will startle in response to a loud sound or sudden movement.
1 month milestone
head lags


Hands predominantly closed

Grasp reflex strong

Hand clenched on contact with rattle
2 month milestone
posterior fontanel closed

head lag when pulled to sitting

grasp reflex fading

binocularity beginning

social smile
3 month milestone
primitive reflexes fading

Actively holds rattle but will not reach for it

coos and babbles
4 month milestones
Drooling begins

Moro, tonic neck, and rooting reflexes have disappeared

no head lag

rolls from back to side

Inspects and plays with hands; pulls clothing or blanket over face in play
4-6 month milestones
Beginning signs of tooth eruption

Birth weight doubles

able to grasp objects voluntarily

sits with support

rolls from back to abdomen

hold bottle

prefers more complex visual stimuli
6-8 month milestones
sits leaning forward on hands

when held in standing - bouncing

transfers objects from one hand to another

responds to name

"baba, dada" - no meaning

increasing fear of strangers

plays peek-a-boo

parachute reflex (8 months)

sits unsupported (8 months)

responds to word no
8-10 months
Pulls self to standing position and stands holding on to furniture

pincer grasp

Labyrinth-righting reflex is strongest when infant is in prone or supine position; is able to raise head

prone to sitting

says "dada, mama" with meaning

Develops object permanence

looks and follows picture in book
stranger anxiety stages
· Protest: Screaming, crying, clinging to parents, May resist other attempts to comfort (can be seen when infant recognizes cues)

· Despair: Sadness, Quiet, appears to have "settled in", Withdrawal or compliant behavior, crying when parents return

· Denial: lack of protest when parents leave appearance of being happy and content with everyone. Shows interest in surroundings, close relationships not established.
10-12 month milestones
cruises or walks holding onto furniture

can manipulate objects

Plays games up-down, "so big," or peek-a-boo

Shakes head for "no"
12 month milestones
birth weight tripled
birth length increased by 50%

walks with one hand held

says 3-5 words beside mama and dada

understands verbal commands-simple

searches for an object even if it has not been hidden, but searches only where object was last seen

may have favorite toy
play 1-6 months
o 1 month
- Seeing faces may produce a quiet calm

o 2-3 months
- Squeals and sounds, still likes faces and high contrast pictures

o 3-6 months
- Will interact with their environment
- Rattles and toys are good here

o 6 month to 1 year
- Peek-a-boo and pat-a-cake
- Imitation of gestures
- Have :friends"
- Will convey wants
- Infants must be played with!!!!
safety promotion and injury prevention
o S - Suffocation, sleep position
o A - Asphyxia, animal bites
o F - Falls
o E - Electrical burns or burns
o P - Poisoning, ingestion
o A - Automobile safety
o D - Drowning
Erikson's stages of psychosocial development
1. trust vs. mistrust (infant)

2. autonomy vs. shame and doubt (toddler)

3. initiative vs. guilt (preschool)

4. industry vs. inferiority (school age)

5. identity vs. role confusion (adolescent)
Piaget's stages of cognitive development
1. sensorimotor (0-2 yrs old)

2. preoperational (2-7 years old) - imagination and intuition but not abstract

3. concrete operational (7-11)

4. formal operational (11 and older) - abstract reason and thought
school age social development
o Peer groups become a sense of independence
o Boys play with girls until end of school aged years when differences are notable
o Aware of social normal
o "best friends"
o Bullying
o Parents remain primary influence
o Play - more rule based or physical
sleep
-11.5 hours at 5 years
- 9 hours at 11 years
screen time for school age
2 hours!
school age effects of hospital
o Separation
- Threat to independence
- Regressive behavior
- Fear of loss of family place

o Physical harm/bodily injury
- Fear of physical harm or bodily injury

o Fear of death

o Loss of control
- May threaten mastery of skills and interferences with sense of accomplishment
Tanner stages
1) childhood

2)adrenarche, breast buds (thelarche)

3) pubic hair darkens/curly, coarsens, penis size enlarges

4) penis width increases, darker scrotal skin, glans dev, raised areolae, pubic hair speads to thighs

5) adult; no longer raised areolae
adolescent communication
o Fluctuate between adult and child thinking and behavior
o Anticipates shifts in identity and adjust course of interaction to meet the needs of the moment
o No single approach is good consistently
o Give support by being attentive

Give privacy!!!
voluntary control of elimination may occur when?
18-24 months
toddlers favorite word?
is no - negativism
toddler cognitive thinking
magical thinking

what they remember is influenced by what they are told
toddler play
- Parallel play - kids are playing next to each other but not playing with each other
temper tantrum
Remain calm and assertive

Do not attempt to reason with a toddler or "give in"

Allow toddler opportunity to make acceptable choices

Maintain routines

Frustration - don't have words to say what they are feeling

Toddlers assert independence

Violent objection to rules and demands - trying to have autonomy and exert their independence
toddler safety
- Falls, poisoning, choking, drowning, car seats, burns, suffocation, dental care, lock cabinets, do not leave unattended in water, check sizes of toys and toy parts, safety plugs in outlets, safety gates at stairs, child safety seats, kitchen and bathroom safety
preschool play
- Imagination
- Drama
- Imitative
- Social beings
- Reality and fantasy can become blurred
· Imaginary friends
preschool communication
o Use simple terms
o Be direct and concrete
o Watch literal words
o Use short, simple sentences
o Be honest
o Communicate through objects such as dolls
o Be quiet and unhurried
o Be confident
o Offer choices
medically emancipated conditions
-STI's
- Alcohol and drug treatment
- Pregnancy
- Contraception
temperature under 3 months and under 2 months
temperature under 3 months is a medical emergency

temperature under 2 months needs to bring to ER to R/O sepsis
active immunity
· Second line defense

· Not functional at birth but must be learned by the body

· Not fully functional until a child is 6 years old

· Immunizations and natural exposure
live virus
Vaccine that contains a microorganism in a live, but wakened state (measles and varicella)
inactivated virus
Vaccine that contains a inactive or killed form (polio and flu)
When can the influenza vaccine be given?
6 months +
immunocompromised can not receive what kind of vaccines?
live
vaccine nursing management
o Health promotion
o Obtain consent - NURSE IS DOING THIS
o Administer vaccine
o Monitor and educate patients about SE/AR
o Determine eligibility
intubation period
· moment you encounter to become systematic
prodromal period
know your getting sick but not getting sick yet (sore throat)
acute stage
actual illness
commonalities between viral infections
o Rash - viral process

o Fever - normal response to fighting infection

· Fatigue, weakness, rash, fever, irritable, tachycardia, vomiting, diarrhea, respiratory difficulties
fever management
Acetaminophen 10-15 mg/kg/dose q 4 hours (max 5 doses in 24 hours) - not used until 6 moa age or older

Ibuprofen 4-10 mg/kg/dose q 6 hours (max daily dose of 40 mg/kg - can be used for younger
chicken pox
o Causal agent : varicella zoster

o Transmission: airborne

o Incubation period : 14-21 days

o Contagious: 1-2 days before onset of rash until all lesions are crusted over

o Prodromal phase: most infectious time, lesions look macular

o Clinical manifestations
- Lesions
· Macular/popular filled vesicles
· Itch
· Erupt for 1-5 days
· May take 1-3 weeks for all lesions to crust
chicken pox complications
· Cellulitis
· Meningitis - infection of covering
· Encephalitis - infection of actual brain
· Thrombocytopenia

· Reyes syndrome -
- Aspirin and certain viral infections
- Encephalopathy
- Liver involvement
chicken pox nursing management
Airborne and contact precautions

To care for pt, insure you rown immunity

Acetaminophen or ibuprophen

Oran antihistamines

Anti-itch lotions

Oatmeal baths

Short fingernails

Change bed linens often

Watch mental status

Acyclovir
shingles
o Seen in children infected with chicken pox before 1 year or those whos immunity is waning

o Unilateral usually

o Follows a dermatome pattern
Macular/popular/clear filled vesicle

o Pain and tenderness
hand, foot, mouth disease
o Usually seen in summer and fall

o Transmission: fecal oral and respiratory
o Contagious: 2 days before rash and up to 2 days after it disappears
o Clinical manifestations
- Hyperangina
- Ulcerative pharyngeal
- Rash on hands and feet

o Fever

o Fatigue
hand foot and mouth complications
rare CNS infection

neonates can have sepsis and multi organ failure
hand, foot. mouth nursing management
Supportive care
· Oral mouth washes
· Hand washing and hygiene
· Rash on hand and feet does not typically itch

Contact and droplet precautions
· Erythema infectiosum (fifth disease)
o Agent: parvovirus B19

o Transmission: droplet and contact, blood products, and transplacental transmission

o Contagious period: most before rash appears - droplet and contact precautions
fifths disease clinical manifestations
Stage 1
· Flu like symptoms
· Prodromal period (up to 1 week before rash appears)

Stage 2
· "lacy" rash on trunk and extremities
· Fiery, red cheeks (slapped cheeks)

Stage 3
· Rash reappears with sunlight or irritation for 1-3 weeks
fifths disease complications
Children with hemolytic conditions, aplastic crisis, arthritis and arthralgias

Pregnancy - can pass through and pass to fetus which can cause anomalies and miscarriage
fifths disease nursing management
Do not care for these patients if pregnant

Standard and droplet precautions
Acetaminophen/ibuprofen

Oatmeal baths

Stay out of sunlight
Roseola (Sixth Disease)
o Human herpesvirus type 6

o Transmission: most likely through secretions - contact precautions

o Contagious period
- Extends from febrile stage until the rash appears
- Lifelong virus shedding

o Sudden high fever for 3-8 days

o Erythematous maculopapular rash when rash subsides

complications:
-febrile convulsions
-ecephalopathy
mumps
o Transmission: contact and droplet

o Contagious period: 1-2 days before swelling to 9 days after onset

o Clinical manifestations
- Fever
- Earache
- Headache
- Pain with chewing
- Parotid gland swelling
- Lymphadenoma
- Meningeal signs
mumps complications
- Aseptic meningitis
- Orchitis
- Sterility
- Pancreatitis
- Glomerulonephritis
- Thrombocytopenia
- Hearing impairment
German Measles (Rubella)
o 3 day or German measles

o Transmission: contact and droplet or transplacental (most will do airborne)

o Maternal antibodies: until about 9 months

o Contagious period: 7 days before onset of symptoms to 5 days after rash appearance

o Clinical manifestations
- Mild disease
- Forschheimers sign
· Pin point petechiae on soft palate of mouth
· Seen in prodromal phase
- Pinkish maculopapular rash
- Begins on face, neck, scalp, and spreads downward over 3-day period
- Rash fades on prior areas when new area becomes involved
Measles (Rubeola)
o Transmission: contact and droplet (most will do airborne)

o Passive maternal immunity until about 12-15 months

o Contagious period: 4 days before rash and 5 days after appearance of rash
Measles clinical manifestations
Prodromal phase (2-4 days before rash
· Feel ill

Stage 2
· Kolpik spots
- 1-3 mm gray or blue-gray spots on mucosa
- Lasts 1-3 days

Stage 3
· High fever
· Conjunctivitis
· Coryza - runny nose
· Cough
· Rash
------Red/purple, blotchy, maculopapular that begins on head, behind ears and is itchy

· Peak 2-4 days after onset
measles complications
- Diarrhea
-Otitis media
- Bronchitis
- Croup
- Encephalitis
- Death
rubella and rubeola nursing management
o Cool mister humidifier
o Suction nose
o Monitor respiratory status
o Antitussives
o Dim lights
o Elevate HOB
o Fluids
o Bed rest
o Vitamin A
Pertussis (whooping cough)
o Transmission: direct contact or respiratory droplets from coughing
o Contagious period: 1 week after exposure
- Most contagious during catarrhal stage
- Communicable for 5-7 days after abx therapy
pertussis stages
o Catarrhal stage (1-2 weeks)
- Nasal congestion, low grade fever, mild cough

o Paroxysmal stage (1-6 weeks)
- Cough more sever/spasms/thick mucous
- Forceful inspiration through a narrowed glottis and stridor
- Cyanosis, post-tussive emesis
- Dehydration

o Convalescent stage (up to 6 weeks after paroxysmal stage)
- Symptoms gradually subside
pertussis management
Erythromycin or azithromycin to infected child and all non-immune contacts
Streptococcus A
there is no vaccine

o Transmission: contact with respiratory secretions or direct contact with infected skin

o Intubation
- 2-5 days (pharyngeal)
- 7-10 days (skin/pyodermal)

o Contagious period
- Highest during acute infection

o Pharyngeal
o Scarlet fever
o Impetigo
strep A scarlet fever
Fine, popular rash in axillae, groin, and neck

'sandpaper" feel

Blanches with pressure

Strawberry tongue by day 4-5

Complications
· Result from extension of strep infection
-Acute rheumatic fever
- Acute glomerulonephritis
- Sepsis
Strep A impetigo
Highly contagious
· Superficial skin infection characterized by minor abrasions, bites, or dermatitis
· Most often occurs on face, neck, arms, hands or legs
· Infection can be spread after scratching an infected site

Lesions are mild painful

Pruritis and burning may be present

Begins as a single erythematous macule

Rapidly progresses to vesical or pustule vesicle

Ruptures leaving a honey colored crust
Impetigo treatment
bacitracin

systemic antibiotics if not responding to topical
impetigo skin care
· Soak area with crusts in warm water
· Gently cleanse with antibacterial soap
· DO NOT touch or pick at
· Wash childs hand a lot
· Keep fingernails short and clean
· Infection control
mononucleosis
o Epstein barr virus
o "kissing disease"
o Transmission: saliva
o 15-25 year old
o Incubation: 4-6 weeks
o Contagious period: 6-18 months

o Clinical manifestations
- Severe sore throat
- Large, red tonsils
- Lymphadenitis
· Neck, groin, armpits
- Fever 7-14 days
- 2-4 weeks activity restrictions
Hepatosplenomegaly
· No sports for 4 weeks

Mildly contagious while fever free
giardiasis
o Intestinal parasite
o The protozoa can curvive for months in the environment
o Transmission: contaminated water, swimming

o Symptoms: abdominal cramps and diarrhea

o Diagnosis: stool specimen for ova and parasites

o Treatment: antifungals
pinworms
o Nematode - enterobuis
o Infects 30% of children

o Symptoms: perianal itching due to female worms migrating out of anus to lay eggs
- With itching, eggs are depositing under nails and on hands
- Then it spreads
rocky mounted fever
o Transmission: wood or dog tick bite

o Intubation: 2-14 days after bite of an infected tick

o No person-to-person transmission

o Symptoms
- Fever, flu like symptoms, HA, muscle pain, chills, rash
- Enlarged liver and spleen

o Complications
- Gangrene of the distal parts of the body from thrombosis
- DIC
- ARDS

o Management
- Early detection
- Obtain Hx
- Physical exam and documentation of any rashes

Doxycycline is the drug of choice - tetracyclines should only be given to 9 yoa or older
Lyme disease
o Transmission: infected deer tick bite

o Intubation: 3-30 days after bite

o No person to person transmission

o Symptoms in children
- Fever, flu like symptoms, painful joints, bulls eye rash
· Expands over weeks

Stage 2 (3-10 weeks after inoculation)
· Multiple erythema migrans
· Cranial nerve palsies
· Arthralgias
· Headache
· Fatigue
· Meningitis

Stage 3
· Most serious
· CNS changes
· Carditis
lyme diseease complications
- Neuro deficits
- Encephalopathy
- Optic neuropathy
- Cognitive and behavioral changes
lyme disease management
Doxycycline for children 9yrs and older

High dose amoxicillin for children under 9 years
cat scratch disease
o Common cause of regional lymphadenitis in children

o Symptoms:
-Painless, erythematous papule at site of scratch
- Regional lymphadenitis
sepsis
May initially just show temp instability, tachypnea, tachycardia, bounding pulses, normal output, warm extremities

As progresses
· Hypotension
· Mottled and cool extremities
· Weak pulses
· Mental status changes
preterm nutrition
More caloric intake (90-120 cal/kg/day)

The act of eating and absorption can be a problem

Breast milk if considered the best calories, fat and protein
breast feeding supplemetns
vitamin D and fluoride
typical volume intake for milk per day for a newborn
about 32 ounces
solid food introduction
infant should be able to sit

-One food at a time to identify allergies
- Begin with rice/oatmeal
- Progress to vegetables and then fruits
- Meats/proteins introduced last
- Seen as a supplement to the breast milk, not replacing it
Failure to Thrive (FTT)
less than 5th percentile
FTT organic
· Disease
· Reflux
· Immunosuppressed
· Neurological disorders
· Metabolic disorders
FTT - nonorganic
feeding disorder
-not receiving enough due to behavior or social issues
growth and dev patterns
o Cephalocaudal
o Proximodistal
o Gross motor skills first
o Fine motor skills second
sensorimotor subsets
o Use of reflexes (birth to 1 month)

o Primary circular reactions (1-4 months)
- pleasure

o Secondary circular reactions (4-8 months)
- Cause and effect

o Coordination of secondary schemes (8-12 months)
- Intentional behavior

o Tertiary circular reactions (12-18 months)
- Curiosity, exploration, and experimentation

o Mental combinations (18-24 months)
- Language development
Types of play
onlooker: children watch but do not play

solitary:play alone with toys, maybe in the presence of others. Interest and attention is focused on their own play

parallel: play independently but alongside of other children, toys are similar to those around them (toddler)

associative: children play together but no organization or cooperation; more like "follow the leader" or playing with similar toys but doing their own things with them, yet having convo together

cooperative: organized play with group
High BSA in the infant promotes
fluid loss
kidneys
cant concentrate urine until about 2 yoa

harder time compensating for acidosis
high respiratory rate in children causes
water loss
respiratory acidosis causes
•Apnea
•Aspiration
•CF
•Pulm Edema
•Ineffective breathing
respiratory alkalosis causes
•Hyperventilation
•Anxiety
•Pain
•Fever
•Mechanical Vent
metabolic acidosis causes
•ingestion of a substance that acts like an acid in the body
-Antifreeze, aspirin

•Body makes too much acid
-Ketoacidosis

•Loss of bicarbonate
-Urine
-Diarrhea
-Medications
metabolic alkalosis causes
•Ingestion of baking soda or antacids
•Large blood transfusion
•Diuretics
•Dehydration
•Vomiting
•Gastric suction
•Diuretics
•Cushings Syndrome
•CF
mild dehydration
vital signs normal

slight thirst

mucous membranes are normal

anterior fontanel is normal

jugular vein visible

cap refill less than 2 seconds

urine decreased
moderate hydration
vital signs slightly increasing

irritable, more thirsty

moderate thirst

dry mucous membranes

decreased tears

anterior fontanel normal to sunken

jugular vein not visible except with pressure

cap refil 2-4 seconds

oliguria
severe dehydration
vital signs very increased

orthostatic

hyperirritable to lethargic

intense thirst

no tears and sunken eyes

anterior fontanel sunken

no jugular vein

cap refill greater than 4 seconds

oliguria or anuria
normal urine output
1-2 mL/kg/hr
severe dehydration rehydration
normal saline bolus and 20 mL/kg/hour
calculating fluid maintenance
up to 10 kg = 100 mL/kg/day

11-20 kg = 1000 mL + 50 m/kg for every kg about 10 kg per day

greater than 20 kg = 1500 mL + 20 mL/kg for every kg above 20 kg/day
colic
•Characterized by vigorous crying and drawing legs up to the abdomen

•Crying more than 3 hours a day for more than 3 weeks in a healthy infant
colic management
•Mylicon
•Gripe water (not homemade)
Hirschsprung disease
inadequate motility causes mechanical obstruction of the intestine

•Absence of autonomic parasympathetic ganglion cells in the colon
•Accumulation of intestinal contents and abdominal distention

signs and symptoms
•Chronic constipation
•Foul smelling stools
•Abdominal distention
•Visible peristalsis
•Palpable fecal mass
•Fecal vomiting
•Malnourishment
•Anemia
•Hypoproteinemia
pyloric stenosis signs and symptoms
•Initially, infants regurgitate slightly after feedings
•Parents may describe baby as a good eater that occasionally vomits
•Vomiting becomes projectile as obstruction progresses
•Vomitus is nonbilious and may become blood tinged
•Infant is hungry, appears irritable, fails to gain weight with fewer and smaller stools
•On palpation, a movable, firm, olive shaped mass in the RUQ
•Visible, deep, peristaltic waves from LUQ to RUQ
intussusception
telescoping of the intestines - obstruction can occur

•Severe abdominal pain
•Vomiting
•Signs of bowel obstructions
•Currant jelly stools
cleft lip/palate repair post op care
•No oral temps
•No straws, pacifiers, spoons or fingers in or around mouth for 7-10 days

Cleft lip
•Spaghetti nipple or rubber tipped syringe

Cleft palate
•Liquids can be taken from a cup, no straws
•Soft foods can be taken off the side of a spoon
•Child is not allowed to feed self

General
•Keep suture line clean
•Apply antibacterial ointment
•Elbow restraints
•No tooth brushing
•Supine or side lying on unaffected side
•Analgesia and sedation
TE atresia or fistula
•Defective separation or incomplete fusion of tracheal folds
•Foregut fails to lengthen and separate into 2 parallel tubes
indications of a TE fistula
Respiratory distress
•Cough
•Choking
•Cyanosis

•Failure to pass suction catheter
•Excessive oral secretions
•Vomiting
•Abdominal distention, especially with crying
TE fistula surgery
•Stage 1
•Ligation of fistula with g-tube placement

•Stage 2
•Ends of esophagus are attached to one another
NG tube placement
nose to earlobe to xiphoid process
biliary atresia
•Acquired late in gestation and manifested a few weeks after birth

•If left untreated, leads to cirrhosis, liver failure, and death in the first 2 years

signs and symptoms
•Inflammation, edema, and hepatic degeneration
•Jaundice - after 2 weeks - LIVER FUNCTION TESTS
•Puritis
•Ascites
•Steatorrhea
•Distention
•Anemia
•Bleeding tendencies
•Ricketts
imperforate anus
•Absent anal opening
•Abdominal distention
•Vomiting
•Absence of meconium
•Presence of meconium in the urine
necrotizing enterocolitis
•Diffuse or patchy necrosis of the mucosa or submucosa occurs in the small or large bowel

Signs and symptoms
•Feeding intolerance
•Apnea
•Fever
•Bloody stools
•Bowel loops
•Absent bowel sounds
celiac disease
•Immunologic disorder
•Characterized by intolerance for gluten
•Impairs absorptive process in the small intestine
•Affects fat absorption

Results in the accumulation of glutamine in the intestines
•Toxic to the mucosa of cells
•Villi atrophy
•Decreased absorption of nutrients

gluten enteropathy
•Decreased fat and protein
•Decreased CHO absorption
•Increased mucosal damage leads to lactose intolerance and fiber intolerance

diagnosis
-serum AGA
diaphragmatic hernia signs and symptoms
•Severe respiratory distress
•Dyspnea
•Cyanosis
•Barrel chest
•Sunken abdomen

Treatment
•Respiratory support
•ECMO
•Inhaled nitric oxide
•Positioning head higher than abdomen
•NG tube to decompress abdomen
•IVF
•Surgical correction
respiratory anatomical differences in children
•Rapid Respirations
-Fewer alveoli
•Periodic breathing
•Brief periods of apnea
•Surfactant is lacking in preemies
•Mucous membranes less ciliated
•Obligate nose breathers
why are children more susceptible and have worsening symptoms of respiratory infections
diameter of airway much smaller
ear infections in child
eustachian tubes are shorter, wider, more horizontal
cardinal signs of mild respiratory distress
•Restlessness
•Tachypnea
•Tachycardia
•Diaphoresis
early subtle signs of respiratory distress
•Mood changes
•Headache
•Change in depth and pattern of respirations
•Flaring nares, retractions, grunt, wheeze or prolonged expiration
•Anorexia
•CNS changes, anxiety, confusion irritability
severe hypoxia signs and symptoms
•Cyanosis, peripheral of central
•Dyspnea
•Hypotension or hypertension
•Dimness of vision
•Somnolence
•Stupor
•Coma
suctioning
•5 sec for infants
•10 secs for children
•Hyperventilate
•30-60 sec of rest between passes
suctioning a pediatric trach
•Premeasure catheter
•Insert catheter, suction on
•Swirl the catheter for about 5 seconds, Suction on
•Remove the catheter slowly, Suction on
•Assess throughout procedure
•Document
apnea
Cessation of breathing for a period of 20 seconds or longer; a shorter period accompanied by bradycardia or cyanosis
when does someone qualify for a tonsillectomy
•7+ episodes in preceding year OR 5+ episodes in preceding 2 years, or 3+ episodes in preceding 3 years
•Sleep apnea
OM
Otitis Media (inner ear infection)
AOM
Acute otitis media Inflammation of the middle ear with signs of infection
OME
fluid in middle ear without symptoms
Croup can be caused by :
•Para influenza I, II, III virus
•H-Flu
•Adenovirus
•Pertussis
•RSV
•Mycoplasm pneumonia
croup is characterized by
•barking cough:
•hoarse cry
•muffled vocal sounds
•inspiratory stridor
•increased use of lower accessory muscles
•varying degrees of resp distress
•increased symptoms at night
•increased agitation and crying
Epilglottitis
airway emergency

step group A

•Epiglottis becomes swollen, cherry red and surrounded with copious secretions
•Edema, severe & painful, obstructs airway
•NO COUGH
•Hypoxia
•Acidosis
•Death

NEVER EXAMINE THROAT
bronchitis
•Inflammation of large airways (trachea and bronchi)
•Associated with URIs
•Dry cough at night that becomes productive within a few days
•Mild and self-limiting
Bronchiolitis
Infection of the bronchioles (smaller air-tubes in the lungs)

hyperinflation of lungs

atelectasis
bronchopulmonary dysplasia
A chronic obstructive pulmonary disease that occurs as a result of acute lung injury
•Has received supplemental O2 and mechanical ventilation
•Lung immaturity is a key factor

signs and symptoms
•Tachycardia, Tachypnea
•Increased WOB
•Retractions
•Prolonged exhalation with increase use of accessory muscles
•Pallor
•Cyanosis
•Activity intolerance
•Barrel chest
-poor feeding
First degree obstruction
Obstruction allows passage of air in both directions
second degree obstruction
air able to move past obstruction in one direction only. Air passages enlarge during inspiration& diminish during expiration

expiration: acidosis
complete obstruction
Air unable to move in either direction. FB and edematous mucosa obliterate passage
Intermittent Asthma
Symptoms less than 2 times/week and <2 nighttime symptoms/month

Tx with SABA
mild asthma
Symptoms <2x/week, PEFR >80% of best
moderate asthma
Symptoms >2x/week, PEFR >60-80%
severe asthma
Continuous symptoms, PEFR <60%, frequent nocturnal symptoms, hospitalizations
guidelines peak flows
green: 80-100%
-continue regimen

yellow: 50-80%
-caution, call MD, increase in therapy may be needed

red: below 50%
-emergency
cystic fibrosis primary characteristics
•primary characteristics are chronic pulmonary disease
•pancreatic deficiency
•high sweat chlorides
CF digestive hallmark
•Meconium ileus in newborn
CF skin
sweat chloride 2-5x normal
Management of CF: GI
replace pancreatic enzymes

high protein, low fat, high calorie

ADEK vitamins
pressure is greater on what side of the heart?
left
left sided HF
crackles; hacking cough; dyspnea
right sided heart failure
1. Jungular Vein Distention
2. Ascending Dependent Edema
3. Weight Gain
4. Hepatomegaly (Liver Enlargement)
5. ascites
hallmark sign of impaired myocardial function in infants
poor feeding
what is a drug used to improve cardiac function and contractility
digoxin
signs of digoxin toxicity
•Digoxin toxicity: arrhythmias an early indicator in children
•Digoxin levels 6 hours after dose
•Potassium low

also causes bradycardia!
nutrition for infant with CHF
high calorie formula
Acyanotic heart defects
left to right shunt

increase pulmonary blood floor

and obstruction to blood blow
Cyanotic heart defects
1. Decreased Pulmonary blood flow
2. Mixed Blood flow
signs and symptoms of defects that increase pulmonary blood flow
•Tachypnea, tachycardia, murmur, congestive heart failure, poor weight gain, diaphoresis, periorbital edema, frequent respiratory infections
signs and symptoms of defects that decrease pulmonary blood flow
•Cyanosis, hypercyanotic episodes (TET spells), poor weight gain, polycythemia
signs and symptoms of defects that obstruct systemic blood flow
•Diminished pulses, poor color, delayed capillary refill time, decreased urine output, congestive heart failure with pulmonary edema
signs and symptoms of mixed defects
: Cyanosis, poor weight gain, pulmonary congestion, congestive heart failure may occur with increased shunting
Defects that increase pulmonary blood flow
PDA, ASD, VSD, AV canal
treatment for PDA
Indomethacin

surgical ligation
defects that obstruct flow from ventricles
•Aortic Stenosis
•Coarctation of the Aorta
•Pulmonic Stenosis
•Hypoplastic Left Heart Syndrome
aortic stenosis
left ventricular hypertrophy

chest pain and dyspnea with exercise

treatment
-prostaglandin
-balloon
coarctation of the aorta
symptoms
-poor feeding, fail to thrive
-legs ae cyanotic
-bounding pulses and high bp in arms

treatment
-prostaglandin
-surgical resection
balloon dialation
pulmonic stenosis
right ventricular hypertrophy

treatment
-surgery
defects that decrease pulmonary blood flow
Tetralogy of Fallot
Tricuspid atresia
pulmonary atresia

right to left shunt
Polycythemia
A disorder characterized by an abnormal increase in the number of red blood cells in the blood

causes sluggish blood

caused from hypoxia
Hypercyanotic/tet spells
acute decrease in SVR caused by crying, feeding, exercise, warm bath, straining, morning rise

-Increased rate and depth of Respirations
-Increased cyanosis, pallor
-Poor tissue perfusion
-Increased heart rate
-Diaphoresis
-Irritability and crying
-Seizures
-Loss of Consciousness
knee-chest position ad other interventions
increases systemic vascular resistance

other
-reduce crying
-calm child
-give oxygen
-administer morphine
Tetralogy of Fallot
Pulmonary stenosis, ventricular septal defect, overriding aorta, hypertrophy of right ventricle

TET spells

endocarditis prophylaxis
tricuspid atresia
no tricuspid valve

right ventricle non functioning

NEEDS another defect

Treatment:
-Prostaglandin E
-Digoxin and Diuretic
-Balloon Atrial Septostomy
-Surgery

No oxygen!
pulmonary atresia
- No communication between RV and PA

-need another defect

-NO OXYGEN
mixed defects
•Transposition of the Great Arteries (TGA)
•Truncus Arteriosus
•Total Anomalous Pulmonary Venous Return
•Hypoplastic left heart Syndrome
TGA
PA and AO switched

pt needs another defect
Truncus arteriosus
one large single vessel

VSD

treatment
-dig
-diuretics
Total anomalous pulmonary venous return
pulmonary vein empties into right ventricle

foramen ovale

Treatment:
-Prostaglandin E
-Digoxin and Diuretics
-Balloon Atrial Septostomy
-Surgery
Hypoplastic Left Heart Syndrome
small left ventricle

avoid oxygen!!!
infective endocarditis
•Inflammation of the lining, valves, or great vessels

•Bacterial, Fungal or Enterococci

•Endocardium injury from turbulent blood flow

•Bacteria attached to injured site an colonize

•Trigger deposition of platelets and fibrin

•Vegetation on leaflets causing regurgitation and heart failure

•Vegetation breaks off to an embolism

•Symptom development between 7-14 days
infective carditis manifestations
•Most common is fever after a surgery
•Fatigue
•Weakness
•Weight loss
•Headache
•Joint and muscle aches
•Diaphoresis
infective carditis treatment
preferred is IV antibiotic
-ampicillin, cefazolin
kawasake disease
•Acute febrile, systemic vascular inflammation

•Small and midsized arteries affected
-Coronary arteries

symptoms
-pink eye
-oral mucosa change
-enlarged lymph nodes
-patchy rash
-peeling skin
diagnostic criteria for kawasaki
5 days along with 4 or the 5 criteria
Kawasaki stage 1
•Abrupt Fever
•Red eyes
•Inflammation of pharynx
•Red cracked lips
•Strawberry tongue
•Puffy hands and feet
•Palms and soles of feet become red
•Cervical lymphadenopathy
•Child is irritable
kawasaki stage 2
•Fever resolves
•Peeling hands and feet
•Coronary artery aneurysms may be noticed
•Myocarditis with EKG changed
•Arthritis
•Symptoms of CHF
•Thrombocytosis and Hypercoagulability
•Most serious complication is MI resulting from thrombosis occlusion (from aneurysms and healing aneurysms)
•Symptoms of MI in Children are Abdominal pain, vomiting and restlessness, pallor and shock
Kawasaki convalescent stage
until ESR and CA return to normal

child appears normal

6-8 weeks

irritation may last

avoid contact sports
rheumatic fever
•Inflammatory connective tissue disorder
•Autoimmune response to Group A beta-hemolytic streptococci
-Strep throat and scarlet fever
rheumatic fever clinical manifestations
•1-3 weeks after untreated Strep Infection

•Carditis:
-inflammation of the heart muscle and heart tissue
-rapid heart rate, fatigue, shortness of breath and exercise intolerance.

•Arthritis:
-swelling, redness and pain in the joints, especially knees, ankles, elbows and wrists.

-Erythema Marginatum on trunk
-No itch, Heat darkens
-Pink macules with blanched center

•Subcutaneous nodules: tiny, hard lumps under the skin

•Fever

•Chorea: involuntary movement of the extremities

•more common in females
bladder capacity for child
10 mL/kk
what may be the first indication of renal disease
protein in the urine
what is present if there is bacteria in the urine
nitrates
single MOST important factor leading to a UTI is
urinary stasis
what bacteria causes most UTI's?
E. coli
UTI manifestations in child
•Poor appetite, vomiting, growth failure
•Enuresis, frequency and urgency urination, dysuria
•Pallor, fatigue, hematuria, abd pain, flank pain
•Fever
vesicoureteral reflux
•Abnormal backflow of urine from the bladder into the ureters and possibly the kidneys

•Reflux prevents complete emptying of bladder, reservoir for bacterial growth

Presents with UTI's graded on scale 1-5
-1-3 handled conservatively, treated with meds
-4-5 surgical repair needed

HIGH INCIDENCE IN SIBLINGS - GENETICS
hypospadias
abnormal congenital opening of the male urethra on the undersurface of the penis (ventral)

NO CIRCUMCISION
epispadias
congenital defect in which the urinary meatus is located on the upper surface of the penis (dorsal)
cryptorchidism
undescended testes

exposes to heat of body which can decrease sperm

increased risk for testicular malignancy
acute glomerulonephritis
•Inflammation of the glomerulus which occludes capillary lumen

acute post strep A
-symptoms usually appear 7-21 days after infection

-may need antihypertensives
-limit sodium and water
-watch electrolytes especially K+
nephrotic syndrom
glomerular injury

•Membrane becomes permeable to proteins

usually related to previous viral illness 4-8 days earlier

MASSIVE protein

steroid treatment which can cause steroid induced cushings
AGN hallmark features
hematuria, cola colored urine

hypertension

milk edema periorbital

school ages

elevated BUN and creatinine
nephrotic syndrome hallmark features
proteinuria, frothy

massive edema

hypovolemia

toddler

labs
-proteinuria 4+
-HYPOalbumin
-elevated cholesterol
-elevated hgb

NO salt diet
hemolytic-uremic syndrome
acute renal failure

Bacterial toxins damages the endothelial cells of capillary wall
-E-coli, salmonella, shigella = occlusion of capillary

-petechial rash
-high BP
-fluids
-blood transfusion
Hypopituitarism hallmark features
by 1 yoa below the 3rd percentile

bone age younger than actual age
TSH levels in hypothyroidism are increased or decreased?
increased
congenital hypothyroidism treatment
levothyroxine (lifelong)
diabetes classification
plasma glucose greater than 200

fasting plasma greater than 126

two hour plasma glucose greater than 200

hgb A1C more than 6.5%
Kussmaul respirations
Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body.
what to do when administering a child glucagon IM
turn on side because child will vomit
Hypoglycemia symptoms
hunger, fatigue, weakness, sweating, headache, dizziness, low bp, cold or clammy skin
Hyperglycemia symptoms
lethargy, sleepy, rapid respirations, ab pain, N/V, DKA
what will toddlers who have diabetes fear
doctors, injections, and blood sugar checks
late signs of type 2 diabetes
•feeling tired
•dry, itchy skin
•frequent infections
•blurred vision
•slow healing of cuts or sores
•polyuria, polydipsia, polyphagia
•numbness or tingling in hands or feet
iron deficiency anemia
microcytic, hypochromic

diagnostic
-ferritin levels
-hgb
lead poisoning symptoms
Symptoms
•Cognitive impairment
•Hyperactivity and inattention
•Headaches
•Abdominal pain
•Agitation
•Clumsiness

Critical level
•Vomiting
•Stupor
•Convulsions
•Encephalopathy
treatment for lead poisoning
chelation therapy for greater than 45

serious side effects
•Hypertension
•Tachycardia
•HA
•Fever
•Nephrotoxicity
sickle cell anemia is a
autosomal recessive disorder - each child has 25% chance
sickle cell anemia clinical manifestations
increase risk for infections

bone pain

chest pain
leading cause of death in children with sickle cell anemia
bacterial infections
vaso occlusive thrombotic crisis
very painful

fever, pain, tissue engorgement
splenic sequestration
• Life threatening—death can occur within hours
• Blood pools in the spleen
• Signs
• Profound anemia, hypovolemia , and shock
aplastic crisis
triggered by viral infection

profound anemia and pallor
medical management of sickle cell anemia
-monitor reticulocyte count to evaluate bone marrow
sickle cell anemia priority treatment
oxygen
pain
safety
lab tests for hemophilia
- Prolonged partial thromboplastin time (PTT)
- Factor VIII and IX
medical management for hemophilia
DDVAP
chemo and radiation ride effects
Bone marrow suppression
•7-10 days after chemo greatest suppression
•Anemia
•Malaise, fatigue

Neutropenia, life threatening
•Aseptic technique

Thrombocytopenia
•No rectal temps
•No needle sticks
•Safe environment
radiation side effects
Nonselective, kills rapidly dividing cells
-Cognitive effect under 3 years devastating
-Bone growth altered
-Secondary cancers later
radiation: side effects late
6 months after

•Cerebral atrophy, white matter degeneration, necrosis, calcification
•Functional changes, encephalopathy, neuropsychological deterioration, focal neurological deficits
•Alopecia within radiation field. After initiation therapy
bone marrow and stem cell transplant nursing care
•Preventing infection until marrow engrafts
colony stimulating factors
granulocytes stimulate WBScs neupogen

others promote recovery of platelets, RBCs (erythropoietin, procrit)
biological response modifiers
interferon-alpha
interleukin-2
when do we replace blood elements?
HGB less than 8

platelet less than 20,000
absolute neutrophil count
WBC x (segs + bands)

normal over 1500
mild neutropenia 1000-1500
moderate neutropenia 500-1000
severe neutropenia under 500
leukemia symptoms
•Lethargy, weakness, pale, dizzy
•Back, leg, joint pain, headache
•Bruising, frequent nose bleeds, petechiae
•Frequent infections
•Fever
•Weight loss
•Swollen nodes
•Night sweats
•Irritability
hodgkins hallmark fetaures
characterized by multinucleated cells
-reed steinberg

presents as localized - large lymph or group of large lymph in neck (painless and moveable)
nonhodgkins lymphoma
rapid widespread involvement

presents as abdominal disease

painless, firm, moveable node in cervical or axillary region
wilms tumor nephroblastoma
solid tumor of kidney

mobile abdominal mass
-DO NOT PALPATE

lung and liver metastasis
osteogenic sarcoma
metastasis to the lungs
Neuroblastoma hallmark features
tumor often silent

changes in eye: racoon eyes and ptosis

•Opsiclonus Myoclonus: dancing eyes

pain or numbness of lower extremities

urine for presence of catecholamines
bones are what in childhood
less dense
Metatarsus adductus treatment
mild cases: just PT

severe cases )greater than 15 degrees): serial casting
hip dysplasia treatment
Pavlik harness
-Infants younger than 6 months
-Dynamic - allows movement
-Ensures hip flexion and abduction but does not allow hip extension or adduction

•Surgery
-Infants older than 6 months
-Spica Cast
Legge Calve Perthes hallmark feature
pain and limp most evident on arising and at the end of activity
scoliosis treatment
•Exercises for mild cases (up to 20°)
•Bracing for moderate cases (20°- 40°)
•Surgery - spinal fusion for severe cases (40°+)

no lifting more than 10 pounds

no sports except walking and swimming
osteogenesis imperfecta manifestations
•Frequent fractures
•Blue sclera
•Increased joint flexibility
•Short stature
•Conductive hearing loss
diagnosis test for muscle dystrophy
gowers sign

elevated CK Levels
most common cause of osteomyelitis
Staph aureus
buckle fracture
Compression injury, the bone buckles rather than breaks
Compartment Syndrome S/S
Pain, Passive stretch(w/hyperextension), Paresthesia, Pallor, Absent/diminished pulses
Assessment of Fractures: The 5 P's
1. Pain and point of tenderness
2. Pulse—distal to the fracture site
3. Pallor
4. Paresthesia—sensation distal to the fracture site
5. Paralysis—movement distal to the fracture site
frontal lobe
associated with reasoning, planning, parts of speech, movement, emotions, and problem solving
upper motor neuron
brain and spinal cord
lower motor neurons
anterior horn cells, nerves, neuromuscular junction
Simple febrile seizure
•Brief, generalized seizure
•Accompanied by a fever
•In a developmentally normal child
Complex febrile seizure
•Either
-Partial
-Prolonged (greater than 15-20 min)
-More than 1 in 24 hours

•Accompanied by a fever
•In a developmentally normal child
meningitis organisms for infants
• H-flu
•Neisseria meningitides
•strep pneumo
•E-coli
•HSV
Kernig's sign
a diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down (pain)
Brudinski's sign
Passive flexion of the neck results in flexion of the legs and thighs.
meningitis manifestations
• Petechial rash & bruising - tumblr test
•Meningococcemia
•Sepsis
•Nuchal rigidity
•Fever
•Elevated ICP
reye syndrome stages
•Stage I
•Vomiting and lethargy

•Stage II
•Combativeness and confusion

•Stage III
•Coma, decorticate posturing

•Stage IV
•Decerebrate posturing

•Stage V
•Seizures, loss of deep tendon reflexes, respiratory arrest
ICP
•Cushing response
•Cheyenne Stokes respirations

"he isnt acting like himself"

LOA
congenital hydrocephalus
•Dandy-Walker Syndrome
•Chiari malformation
•Aqueductal stenosis
•Injury in utero or early infancy
s/s of shaken baby syndrome
•Feeding difficulties
•Bruising, esp. on child below 1
•Vomiting without diarrhea
•Lethargy, sleepiness, progressive decline in LOC
•Decrease verbalization
•High-pitched cry or abnormal crying
•Seizure
•Unequal pupil size
CP clinical manifestations
•Poor head control after 3 mos of age
•Stiff or rigid arms or legs
•Pushing away or arching back
•Floppy or limp body posture
•Cannot sit up w/o support by 8 mos (failure to meet developmental norms)
•Uses only one side of body or only the arms to crawl

-Clenched fists after 3 mos
anecephaly
no brain
encephalocele
protrusion of meningeal tissue or meningeal covered brain through a defect in the skull
spina bifida occulta
a vertebral defect in which arches fail to fuse
meningocele
protrusion of a meningeal sac filled with CSF through a vertebrae defect - no abnormalities of spinal cord
meningomyocele
protrusion of: contains meninges, spinal fluid, nerves and spinal cord
Chiari malformation
•Downward herniation of brain into brain stem
•Respiratory function
•Feeding difficulties
•Worsening of upper extremity function
•Personality changes
early signs of autism
•No babbling by 12m/o or no single or two-word phrases by 2y/o
•Doesn't respond to name
•No smiling, lack of appropriate response
•Excessive lining or stacking objects
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