NUR 218 PEDS EXAM 1 STUDY GUIDE Role of the pediatric nurse Caregiver Educator Advocate Growth & development

Developmental concepts

Specific alterations in function (care of the child with) Hypersensitivity response Otitis media Otitis media is an inflammation of the middle ear and is sometimes accompanied by infection. It’s one of the most common childhood illnesses. About 70% of infants have at least one case of acute otitis media during the first year of life, and 93% have been diagnosed with the problem by age 7. Peak incidence is in the 1st 2 years, esp from 6-20 mos. It occurs more freq among boys and in children who attend daycare centers, in those with allergies, in children exposed to tobacco smoke, and in those who use pacifiers several hours daily. It’s most common during the winter months. Children with conditions such as cleft ip and palate or Down syndrome more often experience otitis media. Breast-feeding appears to be protective against otitis media. In the past decade, an incr number of cases have been observed, and recent changes have been made in recommendations for treatment. Etiology and pathophysiology The specific cause is unknown, but appears to be R/T Eustachian tube dysfunction. Often an upper resp infection precedes the dev’t of otitis media. Pacifier use raises the soft palate and alters dynamics in the Eustachian tube, providing for entry of microorgs from the last nasopharynx. Ethnicity appears to play a role in its incidence (more freq in Amer Indian and Alaska Native). Recurrent otitis media has an incr freq in children of parents who smoke. Children with multiple sublings and those who attend childcare centers have incr incidence. Clinical manifestations Otitis media is the general term for inflammation of the middle ear. Acute otitis media (AOM) is when the child has acute onset of ear pain, marked redniess of the tympanic membrane upon otoscopy, and middle ear effusion. Recurrent AOM indicates repeated bouts of AOM, such as 3 in 6 months, or 4 in 12 mos. Otitis media with effusion (OME) is evidence of fluid in the middle ear w/out inflammation. OME sometimes becomes chronic in nature (more than 3 months) and is more commonly assoc with hearing loss. Infants & young children have characteristic behaviors that can indicate otitis media: pulling at the ear, diarrhea, vomiting, fever, as well as night awakenings with crying (due to incr pressure when prone or supine). Irritability and “acting out” may be signs of a related hearing impairment. Clinical care Dx with otoscope. AOM is diagnosed with certainty when there’s Hx of acute onset, presence of middle ear effusion (bulging or decr mobility of the tympanic membrane, air fluid behind the membrane, or otorrhea/discharge), and S/S of inflammation (erythema of tympanic membrane or discomfort that makes sleep and other activities difficult). Otoscopy includes visual and pneumatic techniques. Occasionally, the middle ear fluid is cultured so that the causative organism can be identified. If the tympanic membrane isn’t intact, the culture is easy to obtain; in cases with repeated antibiotic treatment failures, a tympanocentesis may be done.

        Treatment Antibiotics for 10 days in children under 6. Virus. The ear canal can also be injured by q-tips. etc) Signs of otitis media  painful ear  drainage  irritated canal Nursing care  Verify that the tympanic membrane is intact with an otoscope  Teach families to avoid irritants . Cefpodoxime 10 mg/kg/day. steroids Otitis externa Otitis externa is an inflammation of the skin and surrounding soft tissue of the ear canal. It’s sometimes called “swimmer’s ear” because it’s common in children who swim frequently. or sprays used near the face. or fungi. esp during hot and muggy weather. Sometimes the ear appears swollen and redness or drainage of the canal may be seen upon otoscopic examination. choice of antibiotic depends on the probable organism. decongestants. cefuroxime 30 mg/kg/day Acetaminophen or ibuprofen for pain relief and return for Tx if S/S continue If tympanic membrane is intact. ease of administration. foreign objects. and 5-7 days for children 6 and over AOM Tx is delayed for 48-72 hrs after Dx in children 6 mos-2 yrs with nonsevere illness at presentation AND uncertain Dx. Treatment  remove the dried and flaking epithelium and cerumen  Burow’s solutions or normal saline to irrigate and clean the canal  Steroid eardrops are used to decrease inflammation  antibiotic drops if a bacterial infection is suspected  non-ototoxic ear antibiotic eardrops (eg quinolone) o if the tympanostomy tubes or perforated tympanic membrane  acetaminophen or ibuprofen for pain control  see a provider if no improvement in 48-72 hrs  don’t return to swimming for 5 days  keep the ear canal dry w/ earplugs or a swim cap & gentle blowdrying [the canal] after bathing  don’t put Q-tips or other objects in the ear canal (so that the skin can heal) o also. or skin tab in front of the ear. Amoxicillin with clavulanate or cefuroxime are second-line drugs if IM is preferred o Cefdinir 14 mg/kg/day. this drainage may irritate the canal and lead to otitis externa. or in children 2 yrs and older w/out severe symptoms OR uncertain Dx. and Hx of allergies. The child usually complains of pain and itching. When prescribed. there may be drainage visible in the canal. Any irritation of the canal can become infected with bacteria. topical anesthetic eardrops for several days for pain relief  NOT effective: antihistamines. and may have intense pain when the examiner presses on the tragus. sometimes it represents an allergic reaction. avoid irritants (hair sprays. First line therapy is amoxicillin 80-90 mg/kg/day. If the tympanic membrane isn’t intact because of tympanostomy tubes or breakage of the membrane. previous effectiveness. cost.

 o Eg Q-tips. freq swimming Demonstrate proper instillation of drops & give instructions for use of acetaminophen for pain in the acute period <<paste in pp652-3>> Conjunctivitis Conjunctivitis is an inflammation of the conjunctiva. trauma. olopatadine  Inhibit histamine release from mast cells. depending on the cause of inflammation. viruses. or irritants cause the conjunctiva to become edematous and reddened with a yellow or white discharge. Care  Bacterial o Antibiotic eye meds (droplet or ointment) o Fluoroquinolones (drops or ointment)  Ex ciprofloxacin & other -floxacins o Ceftriaxone for gonococcal in newborns  Gonococcal conj is resistant to penicillin o Erythromycin or tetracycline PO for chlamydial conj  Adenoviral o Comfort measures  Cleaning drainiage with warm cloth. sprays. Allergic conjunctivitis produces watery to thick drainage and is characterized by itching. avoiding reading  Ophthalmic antibiotics as prophylaxis (potential bacterial invasion due to eye rubbing) o For HSV: topical drugs + acyclovir  Allergic o Systemic or local antihistamines o Topical steroids & vasoconstrictors o Decongestants with systemic antihistamines for short-term therapy o Mast cell stabilizers for 3 yo and older  Ex cromolyn. Bacteria. decreasing allergic response  Used for itching  Nursing mgmt o Prophylactic antibiotics after birth o Eye assessments & referrals. There are several types of conjunctivitis. allergies. nedocromil. The main difference between bacterial and viral conjunctivitis is that bacterial conjunctivitis has a purulent discharge that may result in crusting whereas the discharge from viral conjunctivitis is serous (watery). if appropriate o Teach hand hygiene & eye meds instillation to parents o Teach relief of allergic pruritus  Clean washcloths with very cold water Tonsillitis . avoiding bright light. the clear membrane that lines the inside of the lid & sclera.

cervical adenitis. the mucous membranes may become dry and irritated. may need hospitalization Streptococcal pharyngitis (668)  Major complaint is sore throat  Children who have minimal throat redness and pain. chronic tonsillitis. or malformation causing nasal speech or a facial growth abnormality. If children breathe through their mouths continuously. allergies. low humidity o Also. and who have been exposed to someone who has pharyngitis. Tonsillectomy is recommended for recurrent throat infections (3 per year for 3 years). and a low-grade fever. who drools.Tonsillitis is an infection or inflammation (hypertrophy) of the palatine tonsils. they don’t necessarily have tonsillitis. meningitis Iron deficiency anemia (802)  Most common type of anemia & most common nutritional deficiency in children . Although most children with pharyngitis have infected tonsils. mild lymphadenopathy. or who exhibits signs of dehydration or resp distress should be seen by a physician immediately o These could be signs of epiglottitis or diphtheria  Mgmt o Early signs should be treated with oral penicillin or erythromycin (if allergic to penicillin) o Acetaminophen for pain & fever o Cool. It can be bacterial or viral. nonacidic fluids & soft foods. esp boys  The usual source of bleeding is Kiesselbach’s veins (in anterior nares) o Due to irritation from nosepicking. or frozen juice pops to facilitate swallowing & prevent dehydration o Humidification. infections resulting in congestion of nasal mucosa  Bleeding from posterior septum is more serious!!! o Can be life-threatening. exudate. chewing gum. Symptoms include frequent throat infections with breathing and swallowing difficulties. persistent redness of the anterior pillars. glomerulonephritis. Diagnosis requires enlarged tonsils accompanied by pain and inflammation. sinusitis. and enlargement of the cervical lymph nodes. foreign bodies. gargling with warm salt water to soothe irritated throat o Rest o Replace toothbrush after 2 days of meds o Teach to treat immediately since untreated infections can led to rheumatic fever. forceful coughing. Epistaxis  Common in school-age children. ice chips. Symptomatic treatment is the same as for pharyngitis. should have a throat culture o The classic signs of purulent drainage and white patches are not present in all cases of strep throat  NOTE: a child who finds swallowing difficult or extremely painful. Surgery is postponed or children under 3yo because it can stimulate growth of other lymphoid tissue in the nasopharynx.

menorrhagia Clinical manif: pallor. systolic heart murmur o Pica and Plumbism are assoc with Fe-def anemia  Lead absorption increases in the anemic state Clinical therapy: correct the iron deficiency with oral elemental Fe & high-Fe diet. shock Sickle cell anemia (806)  A hereditary hemoglobinopathy (partial or total replacement of normal Hgb with abnormal Hgb) in RBCs o This causes occlusion of small blood vessels. acute chest syndrome w/pulmo HTN o Triggers: fever. These cells are rigid & obstruct capillary flow. malabsorption. emo stress. also. foul aftertaste  Minimize these S/E by incr fluid & fiber intake o Be alert for iron overdose!  ABD pain. Need RBCs to carry oxygen throughout body.     Pathophys: Body needs iron to make hemoglobin. poor nutritional intake o Also 2 to increased internal demands (eg rapid growth periods)  Rapidly growing teens with high-fat. Low HgB affects RBC production. so anemia results in less oxygen to cells & tissues Can occur 2 to blood loss. ferrous sulfate for 4wks Care o Screen at 9-12 mos. folic acid to convert iron to Hgb  Foods high in iron & vitamin C o Ferrous sulfate (oral)  Stains teeth. low vitamin diets  Infants who don’t take in adequate solids after 6 mos 7 are fed only breast milk & formula (neonatal iron stores are depleted by now) o Chronic blood loss (ie hemophilia. parasitic GI illness. so drink through a straw  Can cause black. ETOH consumption . pregnancy. fatigue. emo or phys stress o Precipitating factors: high altitudes. & damage to affected organs  Most common in Blacks and sometimes in Mediterraneans  Pathophys: Hgb in RBCs acquires a crescent shape due to a genetic mutation. Low iron limits hemoglobin production. acidosis. which leads to local tissue hypoxia (which causes more sickling and large infarctions) o Damaged tissues become scarred. poorly pressurized airplanes. ischemia. green. dev’t delay. tachycardia. hypoventilation. & at adolescence (preemies at 4 mos) o Dietary mgmt  Need protein for blood cell production. SOB. irritability o w/prolonged: nailbed deformities. These obstructions lead to engorgement & tissue ischemia (shortage of blood supply). growth retardation. as well as gallstone formation. constipation. vomiting. bloody diarrhea. resulting in impaired function  Ex many children suffer from splenic sequestration (blood trapped in the spleen) & need a splenectomy o Infection rate is high due to impaired immunity & bacterial infections are the leading cause of death in young children o Stroke is a risk. priaprism (sustained erection). or tarry stools. neonatal blood loss. vasoconstriction when cold. 15-18 mos.

throat) to iD source & organism  then. hydration. oxygenation  Parenteral analgesics (eg morphine) via PCA (NOT prn)  Oral & IV fluids  Reduce blood viscosity  Oxygen to provide comfort and decrease incidence of pulmo complications o infection prevention  esp if a splenectomy: decr immune function  daily prophylactic penicillin from 2 mos -5 yrs o double dose from 3-5 yrs  for suspected infection: cultures (blood. ABD< chest. their membranes are more fragile & they only live 10-20 days (instead of 120)  Here. bed rest o Transfusion of RBCs  For improved blood & tissue oxygenation. impaired resps. ANY condition that increases the body’s need for oxygen or alters the transport of oxygen (ie infection. neuro symptoms. aggressive antibiotic therapy o prevention/Tx of assoc complications  Tx for crises: hydration. skin changes are common o Most common reason for hospitalization: acute painful episodes  Sickled RBCs cause vaso-occlusion. dehydration) can result in sickle cell crisis o Sickled cells can resume their normal shape when rehydrated & reoxygenated  BUT. pain mgmt. oxygen. pain. trauma.  basically. ischemia  Pain from avascular necrosis of bone marrow  In back. urine. temp suppression of production of RBCs with HbS  BEWARE! Freq transfusions can cause  iron overload o Iron is stored in tissues & organs cuz body can’t excrete it  Alloimmunization (body makes antibodies to transfusions)  Never infuse cold blood—can incr sickling  Take VS before and q15 min throughout transfusion  If case of transfusion reaction  DC the transfusion  Change the IV to normal saline  Notify the primary healthcare provider o Emo support Thalessemias  A group of inherited blood disorders of hemoglobin synthesis . bone marrow spaces enlarge to make more RBCs Clinical manif: range over all body organs o Children are asymptomatic until 4-6 mos since fetal Hgb is high and inhibits it o Illness from vaso-occlusive events o Infections. reduction in sickling. microinfarction. joints  Chest tightness & SOB o Most common S/S: splenic infarction and hematuria MGMT o Pain control.

which leads to hermosiderin (ironcontaining pigment) deposits in the skin (leads to bronze appearance) Chronic anemia can lead to hyperplasia of bone marrow cavity & thinning of bone marrow cortex o Can lead to skeletal deformities & pathologic fractures  Incl enlarged head & thickened cranial bones o Splenomegaly due to hyperactive spleen & from pooling of cells o Long-term hemochromatosis (excessive absorption & accumulation of iron in the body) dramas include  Gallbladder disease  Liver enlargement & cirrhosis  Growth retardation  Endocrine complications  Jaundice  Cardiac complications (incl heart failure) o Death due to liver disease & infection. death  Usually. vomiting. avoid IM or subQ injections. skin discoloration. shock. apply ice packs to promote vasoconstriction o avoid rectal temps & suppositories.  Defective hemoglobin is synthesized and leads to hemolysis. & providing emo support o control superficial bleeding by applying pressure for 15 min or more o immobilize & elevate affected area. leading to SOB and shock Hemophilia (824-8)  Hereditary bleeding disorders resulting from deficiency in clotting factors  Mostly in boys  Potential complications: internal hemorrhaging. check BP by cuff as infrequently as possible. bloody diarrhea. use only paper or silk tape for dressings. severe anemia. transfusion reactions. S/S start at 6 mos with mobility and tooth eruption  Hemarthrosis & ecchymoses are common  Goal of Tx: control bleeding by replacing the missing clotting factor o Transfusion therapy  Care o prevention & control of symptoms. avoid venipuncture (except for factor replacement). NO heparin flush or aspirin Plumbism (258) o the avg serum lead level is 0. FTT.6 g/dL  the recommended upper level is 10 g/dL . limiting joint involvement & managing pain. hepatosplenomegaly  Look for Fe overload: ABD pain. heart failure from severe anemia or iron overload CARE  Largely supportive o Goal: maintain normal hemoglobin levels  Blood transfusion q2-4wk  May need iron-chelating drug for the iron overload (to excrete Fe via kidneys) o Ex deferoxamine subQ or IV  Hematopoietic stem cell transplant from a sibling  Normal diet for age: include folic acid & Vit C  Avoid iron-rich foods and don’t give iron Assess: pallor.

inhaled dust with lead o why are children at greater risk?  They absorb & retain more lead in proportion to their weight than adults do  Lead is esp harmful to children under 7 yo o Lead interferes with normal cell function 2+  Esp nervous system. reduced birth weight. bones. coma. so it can build up o Chelation therapy: administration of an agent that binds with lead. premature birth  Severe lead poisoning: encephalopathy. education. hypotension. blood cells. disseminated intravascular coagulation. soft tissues (kidney. follow-up  Housekeeping interventions  Damp mopping of hard surfaces. water.o many children with it are poor and live in older houses in inner cities o can experience cognitive defects due to exposure  no know safe level o lead in paint is the most common source for preschool children  also. massive skin & mucosal hemorrhage. floors. and teeth  Lead in bones and teeth is released esp slowly. contaminated food. impaired hearing. baseboards. liver. washing child’s hands & face before meals. growth delays  Ingestion during pregnancy can result in fetal malformations. increasing its rate of excretion from the body  For > 70 g/dL o Care: screening. metabolism of vitamin D & Ca  Neuro effects: decr IQ. & shock  Child is usually under 2 yo and is critically ill & demonstrates multisystem disease o Can progress to critical level w/in 12-49 hrs of onset o S/S: skin turns pink then black (due to tissue damage from reduced oxygen delivery)—may need to amputate limbs due to impaired circulation  Treatment o Antibiotics o Removal from sources of infection o Multisystem shock mgmt o Might also need TPN. influenzae or Strep pneumoniae o it’s thought to be an immune response to the endotoxins of the organism  SUDDEN ONSET o Resp infection  high fever. kidneys. death  Lead gets in the body and accumulates in the blood. sedation & pain relief. freq washing of toys and pacifiers  Nutrition  Increase iron and Ca2+ to counteract their losses  Eat at regular intervals since lead is absorbed more readily on an empty stomach Meninginoccemia (832)  the most severe disease process that follows infection with Neisseria meningitidis or sometimes H. brain). or amputation o Prophylactic antibiotics to close contacts of the child  MGMT o Begin Tx quickly! Probably need to go to PICU . window sills. petechial rash. cognitive defects. and soil. bone marrow. dialysis.

cold milk. water . luxation (partial extrusion). control bleeding. sports. saline. motor vehicle crashes  Predominance during toddlerhood (more mobility)  Encourage protective gear  Mouth has a profuse blood supply. Hank’s Balanced Salt Solution  Otherwise. hydration status o Prevent infection. saliva. maintain nutrition & hydration. mucous membranes. avulsion (complete removal)  In avulsion. allogeneic (usually a sibling) o Assess skin. periodontal ligament holds the tooth in the socket but its attachment is torn  Take child to ED immediately  Fast care is critical (good chances of tooth survival if reimplanted in 30 min) o Handle the tooth only by the crown (top) rather than the root to avoid further damage o Gently rinse the tooth with a stream of sterile saline o Insert the tooth into the socket o Have the child provide gentle pressure by biting a piece of gauze or a moistened tea bag o Transport liquids: Viaspan. monitor for rejection. GI/resp/cardiac function. so bleeding may be extensive for even minor injuries o Use clean cloths to absorb blood & prevent choking on it o Get child to ED  Dental injuries o Usually due to fracture of a tooth. isogeneic (from an identical twin).o o o o o Thorough assessments of all body systems IV infusions to ensure timely & correct admin of antibiotics & other therapies Measure urinary output Meticulous skin care (to preserve integrity of tissues) HSCT (hematopoietic stem cell transplant)  Autologous (own marrow). provide psychosocial support HIV/AIDS Communicable diseases Dental emergencies (673)  Due to trauma during falls.

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