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XVII. PEDIATRICS A. ASSESSMENT: 1. OBSERVATION: Always begin with observation. a.

Behavior: Are they happy, friendly, scared, sad, or withdrawn? b. Appearance: Are they well cared for? (hair clean and cut, hygiene, dressed appropriately for weather) c. Nutritional status: Are they skinny or obese? d. Affect: Is it RIGHT for the situation? e. Consolability: Is the child CONTENT and relaxed? A normal HEALTHY baby should be consolable. f. Position: Are they guarding in pain, do they assume a position that helps them breathe? 2. Distraction Techniques: a. This is done to make sure we get the most accurate PHYSICAL assessment and vital signs. b. Dont forget to talk to PARENTS even before you talk to the child. 3. Vital Signs: LEAST invasive first Observe before TOUCHINGor even talking to them. a. Order of obtaining vital signs: 1) Respirations 2) Heart Rate 3) Blood Pressure 4) Temperature b. Always count RR and HR for one full minute because of IRREGULARITIES. c. If vital signs cannot be taken without disturbing the child, then record the BEHAVIOR with the measurements. d. Temperature: 1) Rectal: Do not use in children over 3 MONTHS months. Most reliable measurement of CORE temperature. 2) Axillary: All ages may be done when an ORAL route is not possible. 3) Oral: Start at age 3. 4) Tympanic: All ages. e. Oxygen saturation: Used to obtain a picture of blood oxygen level through the skin.

1) Check perfusion, skin temp, and edema to determine the best location for sensor probe. 2) Common sites are ORAL and AXILLARY. 3) Record what is going on at the time the pulse ox is measured. Will activity level affect the oxygen level? YES 4) The pulse wave form/intensity display on the oximeter machine should correlate with the childs RADIAL pulse. 4. Nutritional Assessment: a. General growth within ________ to__________ percent for height, weight and head circumference is desired. 1) The fiftieth percentile is the LEAST growth. 2) What happens to the growth rate between 6 and 12 years of age? SLOWS DOWN 3) How much earlier do girls experience the onset of adolescence?___________ b. Lab Values: 1) Hemoglobin/Hematocrit 2) __________________ 3) Creatinine 4) Nitrogen Hint: Always document where temperature was taken, do not add a degree. 5. Physical Assessment: a. Hair 1) Want hair to be _______________ and soft to touch. 2) Poorly nourished it will be _________ and course. b. Fingernails 1) Tell you about hygiene 2) Emotional status c. Skin If skin is pale, it could be a sign of anemia. d. Eyes If eyes are sunken, could be a sign of DEHYDRATION. e. Mouth Assess mucosa color and moisture. f. Teeth Assess hygiene and check their gums. 6. Pain Assessment a. The name of the pain scale is CRIES, its an acronym for: Crying (0-2) Requires increased oxygen (0-2) Increased vital signs (0-2)

Expression (0-2) Sleepless (0-2) The __________________ the score the __________ pain in all the scales. b. FLACC Face, Legs, Activity, ______________, Consolability. 0-10 scale: 0 no pain, 10 worst pain Hurst Review Services 233 c. Wong-Baker rating scale is used on children at what age? Any age but usually 3 years and older. Make sure child has cognitive development and is not developmentally delayed. Scale is 0-5. d. Numerical scale is used at age 5 and older. B. Respiratory System: 1. General Assessment: a. Accessory muscle use. b. Flaring __________ c. Pallor d. Sternal ________________ e. Consolability crying, restlessness and agitation may mean hypoxia. f. Capillary refill greater than________ seconds. 2. Upper Respiratory Disease: a. Laryngotracheobronchitis: Most ________________ type of Croup experienced by children admitted to the hospital and primarily affects children under 5. 1) Causes: Parainfluenza, adenovirus, and RSV 2) S/S: Slight to severe diarrhea ________________ or brassy cough. Increased temperature. 234 Hurst Review Services 3) Tx: Mild croup can be treated at home with steam (hot showers), cool mist humidifiers, car rides with windows down. If symptoms worsen or do not improve, hospitalization is required with corticosteroid therapy. b. Epiglottitis: 1) Causes: H. influenza 2) S/S: Absence of cough Drooling Agitation with the rapid progression to severe respiratory distress.

3) Tx: This is an emergency May require intubation or trach IV antibiotics and corticosteroids c. Tonsillitis: 1) S/S: Difficulty swallowing and breathing so child is a _____________ breather and they have bad breath. Impaired taste and smell, voice has nasal/muffled quality. Persistent couch Swollen tonsils can block drainage of the ear canal and cause otitis media. 2) Tx: Tonsillectomy How should a client be positioned after a tonsillectomy? Place on side with elevated head of bed or __________. Why are brown and red fluids not given post op? We do not want anything to be confused with ___________. What would indicate that hemorrhaging is occurring? ______________ swallowing How many days post op is the client at risk for hemorrhage? Hint: Children with Epiglottitis usually look worse than they sound, and the kid with LTB sounds worse then they look. Hurst Review Services 235 Complaint post op? Sore throat and slight _______ pain Low grade temp Bad breath d. Otitis Media: 1) Patho: What part of the ear is affected? __________ ear The Eustachian tubes are blocked. It usually follows an upper respiratory infection. 2) S/S: What does the tympanic membrane look like with otitis? Bulging and bright ______ 3) Tx: Do heating pads help with the pain? _________ Avoid ________________. And provide soft foods. Lie on the ___________________ side. May not hear you. Avoid smoke. May require PE tubes to keep the middle ear ________________.

The ear tube (grommet) stays in about 6 months and then falls out. 4) Prevention: While tubes are in wear ear plugs when bathing or swimming. Have baby _______________________ for feedings. No bottle propping. AVOID nose blowing. Avoid smoke. 3. Lower Respiratory Tract Disease a. RSV Respiratory Syncytial Virus: 1) Causes: An acute viral infection that affects the bronchioles and includes RSV bronchiolitis or RSV pneumonia. Leading cause of Lower Respiratory Tract Illness in children less than ________ years. 236 Hurst Review Services 2) Risk Factors: Prematurity Congenital disorders Smoke Focus is on _________________ (high risk will get RSV vaccine) 3) S/S: URI Nasal ____________________ Mild fever Dyspnea Nonproductive ________ Tachypnea with flaring nares Retraction and _________________ It is important to know the onset of s/s because the disease will become worse on days _________________. 4) Dx: Nasal ________________. 5) Tx: Transmission _________________ precautions. Teach good hand washing Mild Treat symptoms (supportive care: antipyretics) Severe Oxygen: may need mechanical ventilation IV fluids Suction Antipyretics Antiviral (Ribavirin) Hint: Sign and symptoms can range from mild to severe; can go from cough, runny nose with copious amounts of mucus, to severe respiratory distress!

b. Pneumonia: 1) Causes: Viral (RSV, adenovirus or parainfluenza) Bacterial (Culprit is ____________ pneumonia) children <4 yrs Mycotic (walking pneumonia) primarily in adolescents. Aspiration pneumonia (something other than air gets in the lung) 2) S/S: Fine ____________ or rhonchi with a cough that is productive or nonproductive. Abdominal distention Back pain Fever that is usually high. Chest pain from coughing 3) Tx: Oxygen Fluids Antibiotics Antipyretics Nebulizer Cough suppressant c. Asthma: (see 5th day material) d. Down Syndrome: 1) What type of infection are Down Syndrome children prone to developing? _______________________ Why? Because they have a poor _________________ system 2) The most common type of defect associated with Down Syndrome is ___________ ______________. 3) The primary aim in genetic counseling is to inform the parents of their _____________. e. Cystic Fibrosis: 1) Causes: ____________ trait, and must get trait from _______ parents. 2) S/S: ___________, _________________ secretions. Characterized by ____________ gland dysfunction. (These secrete mucus) Thick, sticky secretions are found in the _____________ and GI tract. 238 Hurst Review Services 3) Dx: Diagnostic test for cystic fibrosis? Positive __________ chloride test At risk for ___________________. The earliest sign in the newborn is the meconium, called _____________. They will have steatorrhea stools, which means ________ and _________.

4) Tx: Enzymes that help improve digestion are the ______________ enzymes. Take _______ minutes prior to eating, do not crush or chew. Need a well balanced, low fat, high calorie, ________ protein diet. Require _______% of the recommended daily allowance. They need to take ________ soluble vitamins including A, D, E, and K. C. Cardiac: 1. Heart Failure: a. Causes: Usually due to congenital defects. b. S/S: 1) Lips turn blue when taking a ______________. 2) Increase pulse at rest, or with slight _______________. 3) Increased respiratory rate 4) Scalp sweating 5) Fatigue 6) Sudden weight _______ c. Tx: 1) Ongoing assessment 2) Control room temperature 3) Sit them up 4) Rest 5) __________ stimuli 6) Cool, humidified oxygen 7) Uninterrupted sleep Fluid retention think heart problems first! Hurst Review Services 239 2. Cardiac Medications for pediatric clients: a. Digoxin: 1) Infants rarely get more than _______cc. 2) Give ______ hour before and _____ hours after feedings. 3) DO NOT mix with medicine, ___________ or fluid. 4) Always check the dose with another nurse. 5) Check the apical pulse for __________________. b. Ace Inhibitors: enalapril (Vasotec), captopril (Capoten) 1) Side effects: ____________ blood pressure Kidney problems ________ cough 2) Action: They block __________________. c. Lasix: To decrease the volume. 3. Nutrition in HF Pediatric Client: a. Well rested prior to eating. 1) Feed them when they wake up or show signs of hunger.

2) ______________ crying. b. Small frequent feedings every __________, no longer than ________________. c. High calories. d. We want to use a ________nipple with a __________ opening so the baby wont have to work so hard to get the formula out. e. May require gavage feedings. f. Usually dont require sodium and water restrictions because of decreased intake. 240 Hurst Review Services 4. Acquired Cardiac Disease: a. Rheumatic Fever is an inflammatory disease that occurs after an infection with ___________ beta hemolytic streptococcus. 1) Major cardiac clinical manifestation is _____________. 2) Therapeutic management is ________________, if they are allergic then erythromycin is the drug of choice. b. Kawasaki Disease is characterized by wide spread ______________ of the small and medium sized blood vessels. Coronary arteries are most susceptible. Treatment: High dose IV immune-globulin _______________ therapy _____________ environment. D. GI System: 1. Cleft Palate/Cleft Lip: a. What is the top nursing diagnosis? Alternation in __________________ 1) Feed with an ______________ nipple or medicine dropper down the side of the mouth. 2) Burp frequently so they will not swallow a lot of _____________. b. Cleft Lip Repair: 1) Position on back or side lying to protect the ___________________. 2) Do not place them ________________. 3) Clean the suture line with ______________ post op. c. Cleft Palate Repair: 1) Place them prone to promote drainage. 2) Avoid putting things in their mouth (thermometers, straws). 3) Soft diet until well healed 4) Are speech defects common? _______

5) When is the best time to do this? Before ___________ development. 6) What type of restraints would be used? ____________ Hurst Review Services 241 2. GER, GERD: GER becomes GERD when complications such as failure to thrive, bleeding, or difficulty swallowing (dysphagia) occurs. a. Positioning: 1) ____________ position with feedings and at night. 2) 30 degree elevated prone position to _________ reflux and improve stomach ____________. b. Feedings: 1) Small frequent feedings of ____________ formula. 2) Breast feeding continues with more frequent feedings or expressing the milk for thickening with rice cereal. c. Medication: H2 blockers, Proton pump inhibitors 3. Esophageal Atresia/T-E Fistula: a. Causes: The saliva cannot make it to the stomach because the esophagus ends in a blind ____________. b. S/S: 1) Why do babies with esophageal atresia not have meconium? Because they never swallowed _____________ fluid. 2) How are they feed? _____________ tube 3) T E Fistula watch for C_____________ Chocking especially while drinking Cyanosis The first feeding needs to be ____________. The top nursing diagnosis is potential for ________________. c. Tx: 1) They will do corrective surgery and the infant is placed on their back with _________ and ________________ elevated. 2) It is not uncommon to see polyhydramnios in pregnancy when the infant has GI problems. The infant does not swallow any amniotic fluid so it just builds up. 242 Hurst Review Services 4. Pyloric Stenosis

a. S/S: 1) Projectile VOMITTING usually after eating. 2) Very hungry 3) OLIVE shaped mass in epigastric region. 4) Peristalsis is obvious. b. Dx: Pyloric ultrasound c. Tx: 1) Hydration 2) Intake and OUTPUT 3) Daily WEIGHT 4) Monitor urine specific gravity 5) _________________ 5. Intussusception: (When a piece of bowel goes backwards inside itself forming an obstruction) a. S/S: 1) Sudden ______________ 2) Cramping 3) Abdominal _____________ 4) Inconsolability 5) Drawing up _____________ 6) Currant ____________ stools (monitor stools) b. Dx/Tx: The definitive diagnosis is through a _________ __________ and this will sometimes fix the problem. Teach sign and symptoms of reoccurrence. 6. Hirschsprungs Disease: a congenital anomaly also known as aganglionic megacolon that results in a mechanical obstruction along the bowel (sigmoid). a. S/S: 1) The presenting symptom is _______________________. 2) Abdominal distention. 3) ____________- like stools that have a foul smell. Hurst Review Services 243 b. Tx: 1) Remove the portion of the bowel that is diseased. 2) May require two surgeries to give the intestines time to heal. 7. Imperforate Anus: There is no __________________ opening, therefore the baby will not pass the _______________. They will do surgery, so they may come back with a ________________ colostomy. 8. Celiac Disease: a. Causes: A genetic malabsorption disorder where there is a permanent intestinal

intolerance to ______________. b. Tx: 1) No food with ___________________. (Vegetable proteins) 2) They cannot have BROW. B____________ R____________ O____________ W___________ 3) They can have RCS. R____________ C____________ S____________ 9. Genitourinary: a. UTI-Urinary Tract Infection: 1) S/S: In newborns and children <2, the s/s may be nonspecific- might even seem to be a GI problem. Failure to thrive _________ problems Vomiting and __________ If left untreated kidney becomes small, tissue may be destroyed and scarring occurs and then the kidney could lead to ______________. Urine smells fishy Predisposing factors (renal anomalies, constipation, bubble baths, poor hygiene, pin worms, sexual abuse) 244 Hurst Review Services Classic symptoms in children >2: Frequency Dysuria Fever ___________ pain Hematuria 2) Dx: Properly collected urine specimen Most accurate method is _______________. 3) Tx: Antibiotic therapy: PO or IV b. Testicular torsion: surgical emergency Painful condition caused by the sudden twisting of the spermatic cord which results in the loss of blood flow to the ___________. Occurs in 1 out of every 40,000 males with a peak onset of _______ years of age. Most common cause of __________ loss in adolescent males. If not diagnosed in a timely manner, they can ________ the affected testicle.

1) S/S: Unilateral pain to affected testicles Edema May experience __________ and vomiting _______________ of the testicles 2) Tx: Surgery E. Hematology: 1. General Information: When caring for a client with a hematologic disorder, always include ______________ isolation as part of their plan of care. High risk for _________________ Encourage __________ __________ Always use sterile technique. 2. Sickle Cell Disease (SCD) This is a hereditary disorder in which the ___________________ is partly or completely replaced with sickleshaped hemoglobin. Sickle shaped hemoglobin or Hgbs cannot carry _________ like normal Hgb. a. S/S: 1) __________ in the areas of involvement. 2) Anorexia. 3) Exercise _____________________. b. Tx: 1) _________ __________ 2) HYDRATION 3) Analgesics 4) Antibiotics 5) ___________ transfusions and 6) Oxygen F. Childhood Cancer: 1. Leukemia: a. This is cancer of the blood forming tissue and proliferation of _____________ white cells. b. When thinking of leukemia always remember immunosuppression, thrombocytopenia, ________________. c. Two types ALL (acute lymphoid leukemia) and AML (acute myelogenous) d. S/S: Fever Pallor Anorexia Petechiae Vague abdominal pain Easily acquired infections

2. Now, Wilms tumor or nephroblastoma are found where? _________________ a. Most common presenting sign is ___________________ or non-tender mass on one side of the abdomen. b. Dont palpate the ______________. c. ____________ _____________ while bathing or moving the client. 246 Hurst Review Services G. Neurology: 1. Hydrocephalus: A disturbance of the ventricular circulation of the cerebral spinal fluid in the __________________. Increase of cranial pressure. a. S/S: 1) Bulging of the _____________ fontanel 2) Dilated scalp veins 3) Depressed ________ 4) Irritability and changes in the __________ 5) High-pitched cry b. Tx: Insertion of a VP (ventriculoperitoneal shunt) 1) Measure the __________ occipital circumference 2) Fontanel and cranial_______________ line assessment 3) Monitor the temperature 4) ___________ position 2. Seizure Disorders: Should consider as a symptom of an underlying disorder rather than a disease. May have a short term memory lapses. School work deteriorates which may be ___________ indicator of a problem. a. Classification: 1) Partial: Limited to a particular location of the brain. An ___________ may be the only manifestation. Simple partial means without loss of consciousness with various sensations: Numbness, tingling, prickling, or pain. Complex partial means they have ______________ consciousness and may be confused and unable to respond. 2) Generalized: Loss of ________________. Types:

Tonic-clonic (formally known as grand mal) Myoclonic (sudden, brief contractures of a muscle or group of muscles; may look like a startle reflex) Absence (formally called petit mal and characterized by a brief loss of consciousness) Hurst Review Services 247 b. Tx: Diagnostic testing: EEG, Ultrasound, CT/X-ray Anticonvulsants Airway, Breathing and Circulation DO NOT put anything in the childs _______________. H. Musculoskeletal System 1. Scoliosis is a lateral curvature and ___________ of the spine. Seldom apparent before age 10, and can be genetic. a. Contributing factors: Heavy __________________ (suitcases, grocery, etc.) Carrying children on hips b. Tx: The 3 Os Observation Orthosis (supports and braces) O ______________ which usually is spinal fusion with rod. I. Early Childhood Conditions: 1. Pin Worms: How are they spread? __________________________ How are they diagnosed? _________________________ a. S/S: Intense rectal _________________ General irritability Restlessness Poor sleep Bed wetting Distractibility Short attention span b. Tx: Mebendazole (Vermox) Hand ______________ Keep fingernails ______________ 248 Hurst Review Services 2. Chicken Pox: Prevent ___________ in the lesions. Home remedies that alleviate itching are ___________ bath, __________ ___________ paste. Is it contagious? ________ If they have an increased risk for severe varicella, Acyclovir is prescribed. J. Middle Childhood Conditions: Head Lice:

Common symptom: _________________ How are lice spread? _________________ contact K. Adolescent Conditions: Mononucleosis: What is the name of the virus that causes infectious mononucleosis? _____________ How is it spread? ____________ intimate contact Tx: Rest, analgesics and fluid The spleen will be enlarged so you dont want them to participate in contact sports.