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Flashcards in Final Deck (417):
1

increased risk of insulin omission

  • poor metabolic control
  • previous DKA episode
  • adolescent girl (weight control, psychosocial concerns)
  • psychiatric dx
  • unstable family situation
  • lower SES
    • limited access to services
  • inuslin pump therapy 
    • short acting insulin
    • malfunction causes immediate impact in insulin amount

2

cerebral edema and intubation

  • intubation predicts poor outcomes
    • CO2 levels < 22 associated with poor outcome
  • avoid intubation if possible

3

compartment syndrome overview

  • myelin sheaths overlay bones and muscles
    • pressure can increase
  • 90% due to IV infiltrate when not checked
    • infusing extravascularly
  • can get from IVs, fractures, burns

4

nursing assessment for ITP

  • neuro - low platelets, at risk for bleeding (brain)
  • skin assessent - generalized petechiae
    • bleeding gum sometimes 1st symptom
  • home with supportive care - no sports, safety
  • monitor for hematuria

5

if a mom brings a child in with a focal seizure, ask:

  • when did it start, how long?
  • first time? seizure hx?
  • family hx?
  • fever? sick?
  • fall? head injury?
  • did he ingest anything? toxic dose, miss a dose? sick or spetic?

6

risk factors for hip dysplasia

  • premie
  • female
  • family hx
  • first child
  • breech during pregnancy
  • large birth weight

7

clinical pathway of aplastic anemia

  • idiopathic
  • low RBC
    • weakness and fatigue, SOB, pale skin
  • low WBC
    • frequent or severe infections
  • low platelets
    • easy bleeding or bruising, bleeding that is hard to stop, petechiae

8

long-term sequelae of cerebral palsy

  • airway - can't get up to increase tidal volume (pneumonia); regurgitation/aspiration
  • circulation - poor venous return, syncopal episodes, hypotension
  • GI - nutrition an issue
  • GU - UTIs
  • Skin - dependent pressure ulcers b/c of bedrest or can't move
  • musculoskeletal
    • contractures
    • osteoposoris - kyphosis, scoliosis

9

simple partial seizure

  • focal seizure with no loss of consciousness
    • no postictal confusion
  • no aura
  • motor symptoms in one extremity
  • sensory symptoms
    • paresthesias
    • auditory/olfactory/visual
    • autonomic (sweating)

10

liquid tumors

  • cancer of the blood or lymphatic system
  • leukemia, lymphoma
  • ALL, AML

11

Wilms tumor

  • tumor of kidney
  • large, rapidly growing, vascular abdominal tumors
    • encapsulated, easier to remove
    • quicker but better prognosis than neuroblastoma
  • peak age 2-3 yo
  • may involve both kidneys

12

skin complications from bed rest

  • pressure ulcer
  • dependent edema

13

skin assessment of liquid tumors

  • pallor - pale, gray overtones
    • usually first predictor when they come in
    • iron deficiency
  • low platelets 
    • bruising, ecchymosis unrelated to trauma

14

hydrocephalus

  • disorder in which an excessive amount of CSF accumulate in cerebral ventricles and/or subarachnoid spaces, which are dilated
  • almost always associated with increased intracranial pressure
  • can be due to:
    • obstruction (non-communicating)
    • impaired absorption (communicating)
    • excessive production (rare)

15

growth hormone deficiency treatment

  • synthetic GH
  • SC injection 6-7 x/week
  • given until bone fusion, decreased growth velocity
  • associated with SCFE, hyperglycemia
  • most benefit happens in 1st year

16

incidence of Ewing's sarcoma

  • 200 cases/year
  • risk factors
    • retinoblastoma
    • environmental
      • radiation and treatment for prior malignancies

17

when to suspect acquired heart disease

  • PMH of viral illness ~ 1 mo
  • high fever
  • exercise/feeding intolerance
  • symptoms of CHF
    • cannot lie flat
    • SOB, WOB
    • diaphoresis
    • enlarged liver
    • peripheral edema
  • palpitations

18

T1DM overview

  • autoimmune
  • most common in childhood
  • complete insulin deficiency
  • needs insulin tx
    • recent intransal insulin not well-accepted

19

truncus arteriosus

  • PA and Ao don't separate
    • includes a VSD - communication
  • complete mixture of systemic and pulmonary return circulations
  • decreased systemic blood flow
    • leads to decreased systemic oxygen transport
  • at risk for coronary ischemia

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20

G6PD

lack an enzyme for RBC production that causes hemolytic crisis with fava benas or sulfa drugs

21

non-accidental fractures

  • child abuse is cause of majority of fractures in child less than 1 yo
    • a child who cannot walk should not have multiple bruises or fractures
    • skeletal survey or bone scan to look at whole picture

22

idiopathic scoliosis incidence

  • female to male ratio ranges 1.5:1 to 3:1
  • increases with age

23

tonic-clonic seizure

  • generalized seizure (formerly grand mal)
  • alternating tonic (stiff and rigid) and clonic (rhythmic jerking) phases
  • impaired consciousness
  • salivation
  • pupil dilation and eye deviation
  • tachycardia and hypertension
  • apnea - chest wall rigidity
  • incontinence
  • postictal confusion & sleep (always)

24

early treatment to prevent sickle cell crises

  • babies tolerate hydroxyuria better
    • will start them early
  • also on penicillin VK + PO
    • to prevent infection by encapsulated bacteria

25

Q image thumb

  • no right ventricle
    • b/c no tricuspid valve (tricuspid atresia)
  • no fetal blood flow to RV, so didn't develop
  • single ventricle physiology

26

open fracture

  • bad, high impact fall that causes skin to break
  • infection control a concern, after ABC

27

hemolytic crisis

  • increased RBC destruction
  • seen with G6PD

28

special peds considerations for fractures

  • femur (blood loss)
  • ankle (growth plate)
  • clavicle (vessels)
    • common in newborns

29

respiratory status of lymphoma

  • cough, SOB, wheezing
  • why would they have respiratory complaints?
    • many lymph nodes in mediastinal cavity
    • may be misdiagnosed as asthma

30

types of anemia

  • RBC not made
  • RBC not healthy
  • RBC made and lost

31

treating Kawasaki disease

  • intra-venous immunoglobulin (IVIG) 2 gm/kg
  • ASA 80-100 mg/kg/day until afebrile for 2-3 days, then 3-5 mg/kg/day for 6-8 wks (or until ESR normal)
  • enoxaparin SQ 6-12 weeks

32

Tx for Ewing's and osteosarcoma

  • challenges: removal and treatment
    • bone doesn't compensate for removal of tumor
  • tx after removal
    • depends on location, size, how involved it was
    • many tx that may or may not be good
    • ex: rotationplasty 

33

4 typical patients who can benefit from palliative care

  1. cure is possible but may fail
  2. premature death inevitable, but Tx may prolong quality and quantity of life (i.e. CF)
  3. progressive conditions w.o curative options where treatment is exclusively palliative, but may extend life
  4. conditions that are not progressive but render vulnerable and susceptible life-limiting complications
    1. severe, medically fragile CP (largest population)

34

obstructive lesions overview

  • low cardiac output
    • decreased perfusion to gut
    • shock
    • myocardial dysfunction
  • elevated left and right atrial pressures (depending on location of obstruction):
    • congestive heart failure, pulmonary edema (over time)
  • over time can lead to LV dysfunction

35

definition of traumatic brain injury

complex injury with broad spectrum of symptoms and disabilities. impact on person and family can be devastating

36

SCD symptoms of eyes

retinopathy, retinal detachment (diminished vision)

37

hemophilia type A

  • missing/low levels of clotting factor VIII (8)
  • 8/10 people have type A

38

anorexia and bone loss

Q image thumb

A image thumb
39

transitioning: necessary vitals

  • glucose stable
    • < 200 mg/dL
  • acidosis corrected
    • pH > 7.3
    • HCO3 > 18 (16)
  • ketosis resolved
  • able to tolerate diet
  • at a mealtime is preferred
    • smoother transition

40

fasciotomy

lateral incision to relieve pressure from compartment syndrome

41

nausea and vomiting during chemo

  • generally begins 2 hours after chemo starts and persists 6 hours or days post chemo cycle
  • increased anxiety
  • food aversions
    • persists beyond illness course, can affect nutrition
  • secondary issues from meds, steroids
  • don't give them their favorite thing until they're feeling better

42

patent ductus arteriosus

  • increased pulmonary blood flow
  • oxygen-rich blood from aorta flows through PDA into pulmonary artery and into the lungs
    • two ways to the lungs: pulmonary artery + PDA
  • amount depends on
    • size of PDA
    • pulmonary and
    • systemic resistance pressures
  • corrected surgically or with medication

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43

restoring intravascular, extracellular volume at moderate pace during DKA episode

  • NS 10-20 mL/kg over 1 hour (closer to 10ml)
    • treat dehdyration
    • may repeat ONCE if clinically indicated
      • no more tahn 40 ml/kg in 1st 4 hours
  • fluids
    • 0.45-0.9% saline maintenance or 1.5 x maintenance
      • no more than 4L/m2/day
    • replace deficit over 36-48 hours
    • therapy should normalize osmolality changes from vomiting and diarrhea and decrease symptoms 

44

primary issue with complex partial seizure patients

SAFETY

45

anemia where RBC is made but lost

  • spleen issues
    • splenic sequestration
  • femur fracture 

46

nursing interventions for septic arthritis

  • derm and drugs and disability
    • antibiotics, resting, keep joint still, raise joint, cool compress for pain, exercise for healing process
  • fluids and electrlytes
    • aspirate joint fluid for cell count, gram stain, culture
  • MRI, ultrasound, good hx, good assessment
    • differentiate between osteomyelitis and septic arthritis 

47

TBI from child abuse

  • usually shaking
  • irritable
  • retinal hemorrhaging 

48

HDL cholesterol

  • builds/maintains cell membranes
  • necessary to manufacture bile
  • necessary to absorb fat and ADEK
  • insulates nerve fibers
  • aids in production of adrenal gland hormones
  • aids in production of sex hormones
  • helps remove LDL
    • carries LDL to liver for breakdown and metabolism

49

assessment QUESTIONS for brain tumors

  • how long? what makes it better? what do you do?
  • can you bend your neck? ruling in/out meningitis
  • is it worse in the morning? do you have emesis with your headache? when, how much?
  • tired?
  • photophobia?
  • PERRLA
  • Glasgow
  • head circumference if fontanels not fused

50

other risk factors for cerebral edema r/t DKA

  • insulin bolus > 0.1 units/kg
  • more fluid and solute in 1st 6 hours
  • younger age
  • new onset
  • longer duration of symptoms
  • severity of acidosis
  • effective plasma osmolality drop from 300 to 285
    • BUT do not see expected rise in serum Na as glucose falls

51

contracoup

opposite side of brain from impact of TBI

52

electrolyte complications from bedrest

high creatinine from muscle breakdown

53

nursing interventions for osteomyelitis

  • blood culture
  • skin care
    • asceptic technique when changing dressings
  • support affected limb
  • pain meds
  • antibiotics
  • well balanced diet to promote healing

54

The B symptoms of lymphoma

  • fever
  • significant weight loss
  • drenching night sweats
  • indicates poorer prognosis of Hodgkins' lymphoma

55

Q image thumb

  • no inferior vena cava
  • big VSD
  • translocation of aorta and pulmonary artery
  • total anomalous pulmonary venous return

56

downside of pump + CGM

  • < 15% downloaded data more often than 1x month
  • 41% discontinued use within 1 year

57

aortic stenosis

  • obstructive lesion
    • blocking blood from coming out of left ventricle into systemic circulation
  • if there's no communication to right side:
    • blood backs up in LV to LA to pulmonary veins and back into lungs
    • overcirculation into lungs
    • tachypnic, may or may not be blue
  • can have same symptoms from other defects, however

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58

pulmonary stenosis

  • narrowing/stenosis of pulmonic valve
  • increased work on RV
  • severity of defect determines presentation
  • can be severe in infants, causing cyanosis
  • treatment
    • initial - balloon valvotomy
    • surgery

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59

musculoskeletal complications from bedrest

  • lose 1-2% of muscle every day
  • decreased strength
  • decreased ROM
  • muscle weakness

60

pathophysiology and treatment of hypercanotic spells (TET spells) in tetrology of fallot

  • occur b/c of change in blood flow. try to:
    • increase systemic vascular resistance
    • decrease pulmonary vascular resistance
  • kids will instinctively squat to push up blood to heart (especially from liver)
    • put babies in fetal position

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61

humalog (insulin lispro)

  • rapid acting
  • onset 5-15 minutes
  • peak 1-2 hours
  • duration of action 3-4 hours
  • 10 units/mL for children < 15 kg

62

restrictive cardiomyopathy: treatment

  • none specific
  • CHF
  • symptom tx options
    • diruetics
    • digitalis
    • vasodilators
    • antiarrhythmics
  • lifestyle changes

63

CNS pathophysiology of drowning

  • 2 minutes to lose consciousness
  • 4 minutes for irreversible brain damage
  • cerebral edema
  • hyperglycemia
  • seizures
    • cause you to swallow water

64

receiving clotting factor for hemophilia

  • can get it at home
  • possibly prophylactically to reduce risk
  • often only after trauma or before surgery
  • don't want bleeds
    • especially in joint or head

65

LDL cholesterol

  • clogs arteries
  • coronary heart disease
  • heart attack
  • stroke
  • death
  • contributes to plaque buildup, athersoclerosis, peripheral artery disease

66

anemia where RBC made but unhealthy

  • sickle cell
  • thalassemia
  • malnutrition
    • not enough iron capability

67

causes of pediatric cancer

  • usually unknown 
    • familial cancers rare in children
  • viral - some associated with Epstein-Barr virus (EBV)
  • 3/1000 develops cancer before age 20
    • leading cause of death from disease in US children
    • cure rates continue to improve
  • secondary cancer from tx
    • radiation
    • chemo

68

risk factors for osteomyelitis

  • poor blood supply
  • recent injury
  • use of injected illegal drugs
  • asplenic patients

69

bone marrow draw

  • drawn from iliac crest or femur with big hollow needle
  • can also infuse fluid into marrow
    • intraosseus line
    • for kids without good veins (short term)

70

pathophysiology of TBI

edema compresses brian and causes increased intracranial pressure, hypoxia, or impaired perfusion

headache does not rule in or out a TBI

71

cardiac physiology

CO = stroke volume X heart rate

influenced by:

  • preload
  • afterload
  • compliance
  • contractility

72

breathing and brain assesment for SCD

  • increased WOB
  • acute chest
    • pneumonia then crisis, or crisis then pneumonia?
    • wheezing, atelectasis, no aeration
    • assess lungs w/o clothes and auscultate all fields

73

nutritional therapy management for pediatric cancer patients

  • many patients malnourished
    • increased metabolic demands
    • lost appetite from side effect of medicines or depression
  • nutritional support for 5% of wt loss
  • monitor albumin and prealbumin levels
  • teach patient to use nutritional supplements
  • enteral or parenteral nutrition may be needed

74

central nervous system tumors

  • requires aggressive, multimodal therapy
  • tumor location is important
    • dictates presenting symptoms
    • determines extent of surgical resection that is safely possible
    • suggests pathological diagnosis

75

inducing fetal hemoglobin

  • can help with sickle cell crises
  • hydroxyuria (chemo drug)
    • bone marrow suppression
    • hair loss
    • fatigue

76

causes of increased intracranial pressure

  • hydrocephalus - increased fluid
  • head trauma

77

unique nursing assessments of neuroblastomas throughout body

  • sinus or orbits of eyes
    • periorbital bruising, proptosis (eye drooping)
  • thoracic/abdominal cavity
    • hypertension
    • bladder/bowel function
    • dyspnea

78

mixed cardiac lesions

  • truncus arteriosus
  • transposition of great vessels
  • double outlet right ventricle (DORV)

79

osteoblasts

build bone

80

bicarb in DKA

  • as metabolic acidosis develops, bicarb used as buffer
  • results in increased anion gap

81

SCD symptoms of spleen

  • infarct in the spleen leads to fibrosis
    • nonfunctioning spleen
    • increased number of infections

82

think like a plumber: pressure, resistance, flow

  • blockage or absence of flow
    • create new pathways
  • where passage is too small
    • enlarge pathway
  • where flow is going the wrong way
    • redirect the flow

83

renal pathophysiology of drowning

  • hypovolemia
  • poor perfusion

84

nutritional status among pediatric cancer patients

  • hematological malignancies vs solid tumors
    • solid tumors have most weight loss and nutritional deprivation
    • liquid tumors - drugs cause hunger and odd food cravings
  • assess: questions
    • how frequently do they eat? diet?

85

Salter classification

ways to classify growth plate injuries (I - IV)

86

treatment of familila hypercholesterolemia

  • diet is 1st step
    • DASH - dietary approach to stop HTN
    • fruits, veggies, whole grains, low fat milk, decreased sugar
    • portion intake, dietary fiber, limit Na intake
  • lower LD - dietary fiber, plant sterols
  • lower TG - dietary fiber
  • statins for > 8 yo
    • lovastatin, simvastatin, rosuvastatin

87

cardiac output

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88

causes of aplastic anemia

  • congential (eg Faconi's)
  • autoimmune
  • toxins
  • viral

89

staging of Hogkin's lymphoma

  • Stage 1 or 2: lymphadenopathy above diaphragm
  • Stage 3 or 4: lymphadenpathy below diaphragm
  • staging laparotomy
    • open child from xiphoid to pubis to take many lymph node biopsies
    • figure out how many nodes involved and where they are in relation to diaphragm

90

differences between Ewing's and osteosarcoma

  • time to present symptoms: 8 mo (E) vs 5 mo (O)
  • age: 12 (E) vs 15 (O)
  • fracture
  • pain, localized, pain at rest
  • fever
  • weight loss
  • challenges with location
  • Ewing's and extraosseous location

91

things to remember on cardiac physical exam

  • all 4 extremity pulses and BP's
  • tachypnea (RR > 50) in a baby may be a sign of too much pulmonary blood flow
  • crackles one of last signs of HF in children
  • be patient, take as much time as needed
  • ask for help/2nd opinion
  • DOCUMENT

92

tumor lysis syndrome

  • cells rupture and burst from toxic drugs
  • risk factors: high WBC and certain chemo agents
  • electrolyte side effects
    • hyperkalemia
    • hypocalcemia
    • hyperuricemia
    • hyperphosphatemia
  • complications
    • acute renal failure
    • cardiac issues
    • neurologic issues
  • early recognition is KEY

93

complex partial seizure

  • focal seizure w/ change/loss of consciousness
  • postictal amnesia
  • motor and sensory symptoms
  • aura (taste or odor)
  • anxiety, fear, deja vu
  • automatisms (lip smacking, chewing, sucking)

94

tricuspid atresia

  • missing or abnormal tricuspid valve
  • obstructed flow from RA to RV - backs up in RA
  • decreased pulmonary blood flow
  • foramen ovale or atrial septal defect often there
    • if not, created temporarily by cath lab
    • otherwise, NO circulation through heart
    • creates mixing of blood - blue babies
  • often occurs with other defects
  • symptoms: cyanosis, dyspnea, tachypnea, growth failure

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95

septic arthritis definition

  • inflammation of joint due to a bacterial or fungal infection.
  • septic arthritis that is due to bacteira that cause gonorrhea has different symptoms and is called gonococcal arthritis

96

differential diagnosis of paroxysmal episodes in children

  • breath holding
  • migraine
  • sleep disorder
  • night terrors
  • movement disorders (tics)
  • toxins and drugs
  • psychological problems
  • don't have electrical disturbances in brain that would classify them as seizures

97

secondary symptoms of Kawasaki disease

  • cardiac: new murmur, abnormality in conductive electricity
  • GI: V/D, abdominal pain, jaundice
  • blood: leukocytosis, thrombocytosis
  • GU: proteinuria
  • respiratory: URI symptoms, cough, rhinorrhea
  • musculoskeletal: joint pain
  • CNS: seizure, facial palsy, paralysis of extremities

98

interrupted aortic arch

  • surgical emergency
  • prenatal care and ultrasounds can prevent this
  • HR will be different, poor APGARS
    • can't sustain systemic circulation AND/OR getting blue blood

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99

nursing assessment for Perthe

  • first symptom is often limping, usually painless
    • may be some mild intermittent pain
  • other symptoms include:
    • hip stiffness that limits movement
    • knee pain
    • limited ROM
    • persistent thigh/groin pain
    • short leg
    • muscle loss in upper thigh

100

long term toxicity of cancer therapy

  • vincristine induced neuropathy
  • osteonecrosis
  • myelosuppression 
  • impairment of function
  • risk of obesity
  • infertility
  • myocardial infarct (esp with mediastinal radiation)

101

ongoing hemodynamic assessments of single ventricle physiology

  • pressures
  • rhythm  - cannot afford to have dysrhythmia
  • rate
  • saturations
  • voltage
  • need to keep preload high to help R ventricle with some passive flow and reduce intensity of workload on RV

102

cardiomyopathy: treatment

  • fluid, Na restriction
  • decrease cardiac workload
    • preload increases and pools
      • can get in but not out
    • compliance decreases
      • cannot constrict down to normal size
  • DVT prophylaxis
    • risk of clots and emboli b/c of pooling
  • transplantation
    • depending on cause and severity

103

congential adrenal hyperplasia

  • females may have ambiguous genitalia
  • autosomal recessive, enzyme deficiency
    • inadequate production of cortisol, aldosterone
  • requires lifelong glucocorticoid replacement
  • any stress causes dysregulation
    • surgery, infection, life stress
    • risk for severe hyponatremia (seizure/shock)
    • baseline steroid dose increased 2-3X usual
  • parents and school taught to give IM hydrocortisone in emergency

104

nursing assessments for hemophilia

  • neuro - glasgow
  • full assessment to look fo rhematomas elsewhere 
    • cerebral
  • joint assessment  - full ROM
  • brusing assessment

105

non-hodgkin's lymphoma

  • lymphoblastic lymphoma
  • burkitts lymphoma
  • large cell lymphoma 

106

vitals of complex partial seizure

  • AIRWAY
  • SAFETY
  • high or low HR
  • high or low RR, maybe some apnea
  • random vitals
  • needs assessment (HR, RR, O2, temp)
  • most of the tiem:
    • slow, less labored breathing with apnic spells (worrisome)
    • issue with children - need to maintain respiratory system

107

growth plate damage

  • suspect even if X-ray is negataive
    • need MRI to confirm
  • infection can spread from growht plate
  • common because bones are stronger than plates in children

108

priorities for tonic-clonic seizure

  • airway
    • b/c of apnea and RR need oxygen right away
    • always in child who loses consciousness
    • can't bag - blow by or nasal cannula
    • may not hear aeration in bases of lungs
  • safety

109

SCD symptoms of brain

  • cerebrovascular accident
    • headache
    • aphasia
    • convulsions
    • visual disturbances

110

thalassemia assessment

  • similar to sickle cell
  • skin - color, breakdown
  • joint pain
  • different presentation

111

nursing assessment for septic arthritis

  • newborns/infants:
    • cries with infected joint is moved
    • fever
    • inability to move limb (pseudoparalysis)
    • irritability
  • children/adults
    • inability to move limb 
    • joint swelling, redness, intense pain
    • fever

112

ventricular septal defect (VSD)

  • most common
  • left to right shunt
    • left side pressure higher than right side
  • hole in septum between ventricles
  • surgical correction, depending on size and patient status
  • without correction
    • CHF
    • pulmonary hypertension
    • growth failure
  • lower down its more muscular but higher up it's more membranous and won't repair on their own (lower ones may if they're small)

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113

complications and side effects of chemo and associated medications?

  • generalized hypersensitivity
    • benadryl
    • stop medications if affecting respiratory system 

114

SCD symptoms of extremities

  • vaso-occlusion and chronic ischemia
    • peripheral neuropathy
    • weakness
    • arthralgia

115

diabetes insipudus overview

  • central (neurogenic)
  • trauma, tumor, neurosurgical procedures
  • ADH deficiency

116

S/Sx of hydrocephalus

  • bulging/full fontanels
  • head circumference
  • irritability (young child)
  • headache (older child)
  • photophobia possibly

117

circulation assessment during chemo

  • assess: heart rate, peripheral perfusion (many chemo meds are cardiotoxic)
    • interventions:
      • cardiac monitor
      • +/- IV fluids (depends on cardiac ejection fraction, echo)
      • assess I&Os

118

nervous system complications from bedrest

  • depression
  • example:
    • women who have a history of depression have a higher incidence of hip fractures

119

treatments for cerebral palsy

  • botulinum toxin
  • oral antispastic drugs
    • benzos, baclofen
  • orthopedic
    • long limb lengthening, shin guards, crutches
  • physical therapy
  • feeding and nutrition
  • skin care
  • GOAL is to stop spasms

120

absence seizures

  • generalized (formerly petit mal or lapses)
  • almost always in childhood (4-12 years)
    • remission in adolescence
  • no warning/aura
  • brief 10-15 seconds
  • motor Sx: lip smacking, eye/face twitch, slight hand movements
  • no postictal confusion or sleepiness
  • minimal/no change in muscle tone
    • may drop object, rarely falls
  • may cluster
  • often misdiagnosed
    • inattention, daydreaming, ADD/ADHD
  • need EEG to confirm presence of seizure activity

121

cardiac exam: heart

  • rate
  • rhythm
  • sounds 
    • distinct vs muffled
    • loud vs weak
  • murmurs
  • clicks
  • palpable PMI

122

types of decreased pulmonary blood flow lesions

  • pulmonary atresia
  • tricuspid atresia
  • tetrology of fallot

123

single ventricle physiology: treatment

  • palliation / staged repair
    • 3 stages
      • neonatal
      • 5-7/8 mo
      • ~ 4 yo
  • long term medical and surgical management
  • family education and support

124

causes of bleeding dx

  • imbalance in clotting factors
  • bad/inadequate platelets

125

osteosarcoma

  • type of cancerous bone tumor that usually develops in teenagers when bone is growing rapidly
  • average age at diagnosis is 15
  • sometimes presents as fracture r/t growing tumor

126

intra-venous immunoglobulin

  • for Kawasaki disease
  • neutralizes circulating antibodies
  • suppresses inducer T & B cells; supports suppressor T cells
  • blocks some macrophage receptors
  • promotes re-myelination
  • reduce prevalence of coronary abnormalities

127

DKA bicarb Tx

DO NOT USE

  • acidosis
    • will correct with insulin and fluid
    • rarely causes hemodynamic instability
  • may increase hepatic ketone production
  • increases likelihood of hypokalemia
  • may increase tissue hypoxia
  • may cause paradoxic acidosis of CSF
    • associated w/ risk of cerebral edema 

128

if a patient comes in with a complex partial seizure, what questions to ask?

  • when did this start, how long?
  • what precipitated?
  • seizure hx?
  • meds (miss a dose, too much of it? sick and meds won't work)?
  • falls?
  • primary issues
    • safety - patients unfocused
    • neuro assessment
    • patient teaching at discharge

129

assessing neuroblastoma in abdomen

  • decreased urine output
  • constipation
  • abdominal tenderness
  • compromised lung expansion

130

differentiate neuroblastoma from Wilms tumor

  • neuroblastoma of abdomen has a lot of secondary S/Sx
  • 24 hour urine sample for uric acid (neuroblastoma)
  • labs - high potassium, catecholamines (neuroblastoma)
  • ultrasounds, CAT scans

131

where to treat DKA

  • Consensus Statement recommends general, PICU or other unit with capacity to
    • support frequent assessment/labs
    • have nursing staff experienced in caring for patient population (low staffing ratio)
    • has written guidelines

132

history questions to ask about seizures

  • what was the child doing
  • did the child complain of being ill or feeling funny
  • trauma
  • medications, poisons
  • arm/leg movements, one side or both sides
  • chewing, automatisms
  • pupils dilated or deviated
  • change in color
  • incontinent
  • aware and able to respond
  • how long did it last
  • lethargic, weak, uncoordinated after waking up
  • loss of memory, confusion

133

nursing interventions for aplastic anemia

  • hand washing to prevent infection
  • provide safe environment so they don't bleed or fall
  • assess for bleeding
  • blood products
  • cellular stimulating factor to make more WBCs
  • platelet transfusion
  • possibly antibiotics

134

atrial septal defect (ASD)

  • left to right shunting
    • higher pressure on left side
  • hole in wall that separates atria
    • possibly foramen ovale
    • possibly defect in week 16

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135

risk factors for febrile seizures

  • male
  • first born
  • family hx
  • risks until 5th birthday

136

interrelations between siblings and parents in families living with children with cancer

  • stressful
  • social
  • adjustments
  • unpredictable
  • separation
  • life changes

137

coarctation of the aorta

  • narrowing/pinching of aorta
    • often at level of PDA (not always)
    • blood backs up behind coarct and flows back to pulmonary artery via PDA
    • if PDA closes, baby is in shock
  • increased blood flow to head and upper body
    • decreased systemic circulation
  • bounding upper pulses, decreased or non-palpable lower pulses
  • systolic BP difference between UE and LE ~ 15-30 mmHg
  • hypotension and acidosis (not enough CO to oxygenate tissues)
  • can cause hypertrophy of LV w/o correction (usually w/in first few days of life)

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138

what is congenital heart disease (CHD)?

  • structural malformation or absence of one or more heart chambers AND/OR
  • deformity of major intrathoracic blood vessel(s) AND/OR
  • postnatal persistence of fetal cardiac structures(s) AND/OR
  • absent or non-functional intracardiac valves

139

tetrology of fallot

  • 4 things wrong
    • pulmonary stenosis
    • RV hypertrophy b/c of working hard
    • ventricular septal defect for some circulation
    • overriding aorta 
      • overrides septum and gets blood from both sides of heart

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140

types of obstructive lesions

  • coarcted aorta
  • interrupted aortic arch
  • aortic stenosis

141

diagnosing seizures and epilepsy

  • positron emission tomography scan (PET)
  • electrencephalogram (EEG) - doesn't always confirm
  • MRI
  • CT scan
  • can diagnose type, epilepsy syndromes
  • normal EEG does not exclude diagnosis of epilepsy
    • need history in conjunction 

142

cardiomyopathy overview

  • disease of heart muscle
  • idiopathic or related to systemic disease that affects cardiac muscle
  • three types
    • dilated
    • hypertrophic
    • restrictive (rare in children)

143

assessment of tumor lysis syndrome/electrolytes during chemo

  • assess:
    • cardiac - stress, fluid overload
    • skin, edema, peripherals
  • interventions:
    • cardiac monitor always
    • neuro checks
    • high flow fluids and strict I&Os
      • not restricted, just monitored 

144

nursing assessment for idiopathic scoliosis

  • school screenings vs primary care visits
  • psychosocial
  • measuring curve

145

dyskinetic cerebral palsy

  • affects term infants and usually results from severe, acute perinatal asphyxia
  • neonatal presentation includes
    • encephalopathy
    • lethargy
    • decreased spontaneous movement
    • hypotonia
    • suppressed primitive reflexes

146

cortex

rich in nerves and vasculature, heals faster

147

Kawasaki disease overview

  • vasculitis aka mucocutaneous lymph node syndrome
    • "infection" of vascular system that weakens walls of vessels
  • one of two leading causes of acquired heart disease in US children
  • etiology unknown
  • 80% children 1-5 yrs
  • pathophysiology
    • acute, diffuse, vasculities of medium size arteries and small vessels of body, particularly coronary arteries
  • potential for coronary artery aneurysm (or anywhere)

148

airway, breathing, brain assessment during chemo

  • assess: respiratory rate, aeration, chest pain, SOB
    • intervention: oxygen, cardiac monitor, pulse ox, pristine exam
  • assess: neurological status - Glasgow
    • intervention: Glasgow, seizure precautions (rails up, O2, cardiac monitor)

149

early pathophysiology of DKA

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150

common DKA complications

  • hypoglycemia
  • hypokalemia

151

bone scarring

  • thickening or irregularity on x-ray
  • when fracture not taken care of properly, there is an irregular line
    • osteoclasts try to come in and clean it up but because it's not set properly, they can't do a good job
  • can inject a dye to see metabolically active areas 
    • osteoclasts trying to heal, get rid of scarring

152

buckle fracture

  • "toddler fractures"
  • little nub or area where there was a bruise or break
  • shor term fiberglass cast (2-3 weeks)
  • kids may be missed
    • challenging pick-up
    • but will heal very well

153

best control of diabetes

  • use of inuslin pump
  • BG checks > 5x /day
  • bolus before meals
  • use an insulin/carb ration based on meal
  • insulin dose for snacks

154

DKA assessment

  • severe DKA
  • dehydration
  • buffer system overwhelmed (bicarb low) - primary mechanism
  • elevated RR
  • hyperglycemic
  • K+ high normal
  • low bicarb

155

complications of hyperthyroidism

  • risk for thyrotoxic crisis
    • "thyroid storm"
    • triggers: stress, infection, surgery
    • hypermetabolic state - emergency
    • tachycardia, hyperpyrexia
    • Tx: beta blockers, supportive
  • risk for atrial fibrillation

156

hypertrophic cardiomyopathy: treatment

  • beta adrenergic agonists
  • calcium channel blockers
  • diuretics and inotrope with cauation
  • pacing
  • surgical resection

157

cerebral edema r/t DKA

  • develop in first 3-12 hours of therapy
  • 0.3-1% of children with DKA
    • rare in adults
    • children may have mild cerebral edema that is asymptomatic 
  • pathophysiology not identified
    • recent studies support vasogenic cerebral edema, reperfusion injury
  • most common cause of morbidity & mortality (25%) in KDA in pediatric patient

158

fracture treatments

  • cast
    • plaster vs fiberglass
  • sling
  • splint
  • traction
  • operative fixation

159

vitals of simple partial seizures

  • ABCs - might not be immediately critical but always worry about airway
    • color, cyanosis?
    • distressed?
    • aware, awake, responsive?
    • perfusing?
  • tachypnic, w/ or w/o fever
  • tachycardic
  • O2 probably at 99
  • possibly fluctuating temp if not a febrile seizure
  • patient usually not distressed 

160

pulmonary pathophysiology of drowning

  • as little as 3 ml/kg of water can alter pulmonary gas exchange
  • often head injury or spinal cord inury involved in near-drowning
  • pulmonary vasoconstriction and hypertension
  • disruption of alveolar surfactant

161

types of bone tumors

  • osteosarcoma
  • Ewing's sarcoma
    • malignant round cell
    • can be in genitourinary tissue too
  • management is identical

162

circulation assessment of liquid tumors

  • poor perfusion
  • poor distal pulses
  • tachycardic - decreased RBCs

163

thalassemia presentation

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164

risk factors for cerebral palsy

  • random mutations
  • maternal infections
    • rubella, varicella, cytomegalovirus, toxoplasmosis, syphilis, toxins, bacterial meningitis)
  • premature birth
  • low birth weight
  • fetal stroke
  • lack of oxygen
  • infant infections
  • traumatic head injury

165

normal hemoglobin

Hb-A (alpha2-beta2)

166

dilantin side effects

  • huge dental mess - effects eruption of future tooth growth
  • speech impediment
  • cavities
  • exensive dental work
  • bacterial endocarditis
  • tooth discoloration
  • nutrition issues

167

causes of generalized seizures

  • fever
  • head trauma
  • epilepsy
  • infection
    • sepsis, meningitis
    • syphilis, gonorrhea
  • drug ingestion
  • dehydration (hypo/hypernatremia)
  • cardiac problem/underlying dx
  • some meds
  • tumors

168

diagnosis of diabetes

  • polyuria
  • polydipsia
  • polyphagia
  • fasting blood sugar > 126 mg/dl
  • random blood sugar > 200 mg/dl on 2 separate occasions

169

lymphoma

  • cancer of lymph nodes or spleen
  • alteration in WBC production in lymph nodes
  • can metastasize from lymph to blood
  • Hodgkins or non-hodgkins

170

transfusion reactions

  • allergic: urticaria, itching, respiratory distress
  • hemolytic: fever, chills, hematuria, chest pain
  • febrile/septic: chills, fever, headache, decreased BP
  • volume overload: CHF

benadryl could mitigate future rxns

shouldn't see a change in vitals if there is NO rxn

171

Novolog (insulin aspart)

  • rapid acting
  • onset 10-30 minutes
  • peak effect 1-3 hours
  • duration of action 3-5 hours

172

define pediatric palliative care

  • interdisciplinary specialty 
  • goal of ensuring best quality of life for children with life threatening illnesses
  • by minimizing suffering from distress
    • physical
    • psychological
    • emotional
    • spiritual 

173

transitional circulation

  • Fetal --> Neonatal
  • intracardiac shunts --> no intracardiac shunts
  • High PVR --> low PVR
  • Low SVR --> High SVR
  • Low CO --> High CO
  • gas exchange in placenta --> gas exchange in lungs 

174

diabetes disparities

  • minorities more likely to NOT have a pump
  • the group with the lowest pump use (after adjusting for SES) had higher A1c, more dKA, more severe hypoglycemia, 9X mortality

175

bladder and bowel assessment during chemo

  • asses: urine output and stool
    • complications depend on tumor location
    • diarrhea and hematuria from chemo, radiation
    • complications from metastasis
    • opioids and constipation
  • interventions
    • diet for diarrhea, IV fluids if persistent
    • urine dip for hematuria
    • bowel sounds 

176

carb:insulin ratio

  • to adjust for carbs eaten at meals
  • gm carbs : 1 unit insulin
    • or "carb unit" - 15 gm carbs = 1 carb unit
    • 15:1 - for every 15 gm carbs take 1 unit rapid acting insulin
  • correction formula based on
    • actual blood glucose - goal is 50-100
    • BG 150/50
    • for every 50 points the blood glucose is over 150, take 1 unit rapid acting insulin

177

bone remodeling

  • osteoblast and osteoclast activity
    • want them in balance
  • increase osteoblasts by low impact exercise
    • weight bearing is best, but any movement
    • physical therapy for bed-ridden child
  • estrogen turns off osteoclasts
    • menopausal women ahve problems with osteoporosis
    • especially in spinal colum
    • especially with bad diet and/or no exercise

178

concerns/complications for hyperglycemic hyperosmolar syndrome

  • more profound dehydration
  • greater electrolyte deficits
  • higher risk for mental status changes
  • more frequent complications, higher mortality rate
    • 10X greater than with DKA

179

decreased pulmonary blood flow: overview

  • cyanotic heart disease
    • obstruction of flow to lungs and cannot be oxygenated
    • pulmonary stenosis, tetrology of fallot, tricuspid atresia
  • degree of cyanosis
    • dependent on degree of shunting or obstruction
  • long term problems
    • polycythemia, clotting abnormalities, cerebral infarcts, pulmonary vascular disease
  • supportive therapy
    • PGE1 (prostaglandins)
    • to keep PDA open until defect can be corrected

180

leukemia

  • cancer of blood
  • alteration in WBC production in bone marrow

181

humulin R, novolin R insulins

  • regular insulin
  • only type given IV
  • onset 3 minutes IV, 30 minutes SQ
  • peak effect 2-4 hours SQ
  • duration 6-8 hours SQ
  • prime or not prime?

182

normal hemostasis pathway

  1. damage to vessel wall
  2. platelet plug
  3. fibrin clot

183

3 catgories of idiopathic scoliosis 

184

nursing teaching points to prevent crisis

  • more frequent exacerbations and hospitalizations have poorer prognosis
  • education re: antibiotics and compliance
  • understand precipitating events
    • hydration, oxygenation, extreme temperature
    • exercise, alcohol, vomiting
    • fatigue, pregnancy, swimming

185

SCFE is common in:

  • 11-15 yo, especially boys
  • obese
  • growing rapidly
  • homrone imbalances s/t other conditions

186

SIADH treatment

  • fluid restriction (2/3 maintenance)
  • +/- diuretics

187

canal

  • hematopoesis - blood storage
    • especially in long bones (femur)
    • can lose liters of blood into your thigh in minutes

188

nursing assessments for aplastic anemia

  • similar to SCD and thalassemia
  • derm
    • petechiae, ecchymosis, brusing - from bleeding
  • GI
    • hematuria
    • heme-positive stool
  • low grade fever, risk for infection

189

how many fractures involve growth plates?

20%

190

spastic cerebral palsy

  • upper motor neuron, hypertonia, hyperreflexia, extensor plantar responses and clonus
  • affected patients have slow effortful voluntary movements, impaired fine-motor function

191

history of palliative care

  • ~55,000 infants, children, adolescenst die in US each year of complications from prematurity, congenital defects, genetic dx, injuries, malignancies
  • 23,000 babies die w.in first year of life
  • 65% of children who die in PICU had chronic or pre-existing condition

192

neuroblastoma

  • most common solid tumor occurring outside cranium
  • average age: 2 years
  • occurs anywehre along sympathetic nervous system
    • abdomen, adrenal, thoracic regions
  • neural crest cells 
    • why it's a neuroblastoma

193

long-term brain function in children with hydrocephalus

usually long-term executive function problems, but not necessarily mental disabilities 

194

risk factors for pressure ulcers

  • prematurity
    • fragile skin, little fat, don't move
  • critical illness
  • neurological issues
    • spinal cord injury
    • myelomeningocele
  • nutritional deficit
  • tubes, pressure, bed rest

195

assessment for hydrocephalus

  • vitals
    • worrisome = high systolic, bradycardia, apnea (late findings r/t increased intracranial pressure)
  • pulses LE/UE
  • fluid restriction
  • Glasgow
  • pupil checks - PERRLA?
    • prolonged increased intracranial pressure can herniate brainstem and cause full/dilated/blown pupils

196

respiratory system in DKA

  • related to metabolic acidosis
  • exacerbates decreased bicarb
  • kussmal breathing (buffer system has been overwhelmed)
    • moved from primary to secondary system

197

fetal hemoglobin

  • Hg-F
  • fetal hemoglobin is still normal even with two copies of the Hb-S gene

198

blood transfusion for SCD

  • improve oxygenation
  • too frequent = iron overload
  • iron-chelating drugs 
    • deferoxamine

199

idiopathic scoliosis definition

  • asymmetry of shoulder height, scapular or flank shape or hip height
  • sideways curve of backbone or spine
    • often S or C shaped
  • most common in late childhood/early teens when growth is fast
  • girls more likely than boys, genetic predisposition
  • symptoms include leanign to one side, uneven shoulders/hips

200

lantus (glargline insulin)

  • long acting
  • onset 1-2 hours
  • peak - no pronounced peak
  • duration 18-24 hours

201

unique assessment of retinoblastoma

  • cat's eye
  • complaints of poor vision
  • one or both eyes turning inward or outward
  • pain from increased pressure as tumor grows
    • later finding
  • poor tracking
  • manual palpation of face - bruising, indentation
  • lid lag or eye deviation

202

incidence of aplastic anemia

  • 500 people diagnosed every year
  • more common in young adults
  • most cases of severe aplastic anemia are autoimmune disorders

203

diabetes insipidus teaching

  • signs of dehydration
  • how/when to give DDAVP (bedtime dose)
  • school
    • extra bathroom breaks, extra water/fluids

204

characteristics of pediatric cancer

  • rapidly dividing/growing cells
  • do not follow normal cell signals
  • do not self-destruct (apoptosis)
  • something in the patient's genes has gone awry
  • associated with chromosomal abnormalities

205

nursing interventions for child with increased intracranial pressure

  • neuro - Glasgow
  • head of bed up
  • strict I&Os
  • labs
  • urine output
  • GI
  • head circumference
  • fontanelles

206

how to prevent late findings of hydrocephalus

  • positioning - keep head up 30-45 degrees
  • vitals
  • neuro exam
  • strict I&Os
  • pupils
  • dark room, minimal stimulation

207

SCD symptoms of skin

decreased peripheral circulation (leg ulcers)

208

generalized seizure

involve both hemispheres

209

incidence of retinoblastoma

  • 250 to 250 children/year
  • 4% of all cancers in children younger than 15 yo
  • 40% of patients have genetic defects that leads to multiple tumors in one or both eyes
    • hereditary or germline retinoblastoma
    • usually diagnosed before age 1

210

pharmacologic support of single ventricle physiology

  • catecholamines
  • afterload reducers
  • prostaglandins
  • diuretics
  • medication education

211

osteoclasts

break down bone

212

dilated cardiomyopathy: overview

  • etiology unknown
  • dilated LV and systolic dysfunction
  • effects both systolic and diastolic function
  • +/- RV dysfunction
  • results in CHF
  • run risk of thrombus in legs
    • CO to legs is bad, venous return is bad

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213

family concerns r/t diabetes

  • intial diagnosis
    • grieving r/t chronic diagnosis
    • guilt, sadness
  • implications for lifestyle
    • emergency management
    • planning always involved
  • technology experts
  • math wizards (counting carbs, mixed foods)

214

sickle cell anemia testing

  • newborn screening (mandated)
    • can prevent risk of stroke, pneumonia
  • genetic testing (prenatal)
  • 20% of children with sickle cell do not make it to their 21st birthday despite tx and management

215

sickle cell hemoglobin

  • Hb-S
  • still works but causes RBC to be misshaped and not flow through vessels

216

diabetes insipidus pathophysiology

  • water loss through urine
    • dilute: low SG, low glucose, low osmolality
  • younger child, more rapid dehydration
  • treatment
    • fluid replacement, including urine output
    • IV vasopressin initially, then DDAVP

217

physical assessment of tonic-clonic seizure

  • oxygen, blow by, nasal cannula
  • airway, breathing, circulation
    • BP, peripheral pulses, skin, cap refill
  • Glasgow
  • IV if possible, if not - suppository (valium, ativan)
  • don't give maintenance dose - need rescue
    • plus, may have had too much already
  • labs - tox screen, electrolytes (Na, K), CBC (infection), blood culture, D- stick in the meantime for hypoglycemia

218

bedside glucose monitoring

  • standard allowable error rate is 15-20%
    • ex: at glucose of 60, range = 50-70
    • be aware of error range
  • Hct
    • low overestimates glucose
    • high underestimates glucose
  • other factors affecting accuracy
    • creatinine, bilirubin
    • pH
    • TCO2 level
    • high PaO2

219

dermatology assessment for SCD

  • dusky
  • some clubbing
    • hypoxia
    • small vasculature don't do well under low oxygenlevels
      • compensate to perfuse better by enlarging vessels at end of digits

220

Legg-Calve-Perthes disease definition

  • avascular necrosis of femoral head
  • occurs when ball of thighbone in hip does not get enough blood, causing bone to die
  •  

221

status epilepticus

  • continuous seizure lasting more than 5 minutes or a series of seizures with no return of consciousness during 5 minute period
  • medical emergency
  • AIRWAY (ABC)
  • medications
    • benzo (ativan, valium)
    • phenobarbital
    • phenytoin (dilantin), fosphenytoin (Cerebyx)

222

locating ausculation points in cardiac exam

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223

pressure ulcers in children

  • occiput 31%
  • sacrum 20%
  • foot 19%

224

drug assessment for SCD

  • oral penicillin - compliance issue
    • low dose but susceptible to UTIs, secondary infections
  • multi-vitamin

225

define hemophilia

  • usually inherited
  • little or no clotting factor
  • type A and B

226

D, E, F, G, M assessment for liquid tumors

  • D: unsuccessful antibiotics
  • E: falsified high WBC - not effective or mature
    • at risk for infection
  • F: not necessary dehydrationed - maybe from low-grade fever
  • G: no initial effects
  • M: achiness - bone marrow in overdrive (painful); muscle weakness

227

incidence of perthes

  • boys 5x more than girls
  • 4-10 yo
  • bilateral 10-15%
  • 1 in 12,000

228

cyanotic infant - respiratory or cardiac problem?

suggests cardiac IF:

  • CXR - clear lung fields AND
  • ECG - normal for age AND
  • hyperoxia test
  • echocardiogram
    • structure and function
      • contractility
      • compliance
      • flow in and out

229

right to left shunting

  • unoxygenated
  • from pulmonary circulation to systemic circulation
  • body receives unoxygenated blood
  • cyanotic 

230

bad prognostic finding in cancers of the blood

many WBCs with high % being immature

231

genetics of T1DM

  • HLA gene typing - DR3 and DR4
    • sharing two haplotypes: 12-24%
    • sharing one haplotype: 4-7%
    • sharing neither haplotype: 1-2%
    • identical twins

232

focal/partial seizures

involve 1 hemisphere

233

electrolyte pathophysiology of drowning

imbalances related to salt or fresh water submersion 

234

  • infantile 0-3 years
  • juvenile 4-9 years
  • adolescent > 10 years

235

SCFE nursing interventions

  • bedrest for weeks
  • try to stabilize as minimally as possible
    • no pins, traction, bedrest
  • osteotomy if necessary
  • crutches, pain, post op skin assessment
  • nutritional issues

236

preload

end diastolic volume: volume of blood in ventricles at end of diastole but prior to contraction

237

hemophilia type B

missing/low levels of clotting factor IX (9)

238

cardiac exam: lungs

  • aeration
  • symmetry
  • adventitious breath sounds
  • presence and/or radiation of murmurs
    • back, axilla

239

pathophysiology of CHD lesions

  • increased pulmonary blood flow
  • decreased pulmonary blood flow
  • obstructed pulmonary and/or systemic blood flow
  • mixed lesions

240

nursing assessment/interventions for child with cerebral palsy

  • airway mangement
  • brain imaging and EEG
  • skin - huge issue
  • nutrition - often with NG tube
  • musculoskeletal
  • social, family

241

anemia, pancytopenia, neutropenia during chemo

  • uncontrollable nose bleed associated with gagging, choking, aspiration
  • interventions:
    • direct pressure, ice packs, compression up nares
    • cauterize
    • humidified air
    • don't pack - won't stop bleeding, will cause aspiration
    • can stent capillaries with foley catheter
    • fresh frozen plasma and RBCs for extensive bleeding

242

late pathophysiology of DKA

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243

Q image thumb

  • no left ventricle
  • aorta does not get blood flow b/c of aortic stenosis
    • atrophies
  • no distal blood flow to ventricle b/c of aortic stenosis AND mitral valve atresia
  • single ventricle physiology 

244

SCD symptoms of digits

painful swelling of fingers and toes

245

DKA glucose Tx

  • hyperglycemia will resolve before acidosis/ketosis
    • when glucose 250-200:
      • continue insulin, add dextrose to prevent swings to hypoglycemia
  • decrease glucose 50-100 mg/dl/hr
    • faster may lead to cerebral edema and hypoglycemia 

246

SCD symptoms of liver

  • impaired blood flow from capillary obstruction leads to enlargement and scarring of the liver
    • hepatomegaly
    • cirrhosis

247

cat's eye

  • white-yellow mass or glow seen through pupil
    • usually first noticed when flash is used w/o red eye reduction
  • normally eye is red in response to camera flash, but retinoblastoma causes center of eye to have a white glow

248

aura

  • specific sensation that may occur before seizures
  • 10 seconds to five minutes, varied
  • anxiety and fear before seizure
    • may be easier to manage or intervene

249

types of increased pulmonary blood flow lesions

  • PDA
  • AV canal
  • VSD

250

Curriculum Core Topics for diabetes

  • describe diabetes disease process and treatment options
  • incorporate nutritional management into lifestyle
  • incorporate physical activity into lifestyle
  • use medications safely and for maximum therapeutic effectiveness
  • monitor blood glucose and other parameters & interpret and use results for self-management decision-making
  • prevent, detect, treat acute complications
  • prevent, detect, and treat chronic complications
  • develop personal strategies to address psychoscoial issues and concerns
  • develop personal strategies to promote health and behavior changes

251

presentation of coarctation of aorta: young children

  • headache, irritability
    • children
  • edema in periphery and in dependent area (genital/perineum)
  • decreased LE pulses, difference between UE and LE pressures

252

goals for diabetes management

  • type 1
    • 0-6 years
    • 6-12 years
    • 13+ years
  • HbA1c measure of chronicity & severity
  • most improved 3-6 mo after dx

253

unique assessments for brain tumors

  • increased ICP
    • headache
    • vomiting (especially in the morning)
    • lethargy
    • fontanels?
  • infants
    • delay/loss of developmental milestones
    • irritability
  • school age
    • decline in school performance
  • cranial nerve deficits (positive Babinski)

254

anemia definition

anemia is a condition in which the body does not have enough healthy red blood cells

255

SCD symptoms of lungs

  • infection
  • acute chest syndrome
    • pain, infection
    • cough, fever, tachypnea
    • thoracic bone changes

256

risk factors for infantile hydrocephalus

  • birth weight
  • prematury (
  • low socioeconomic status
  • maternal diabetes

257

growth hormone deficiency

  • decreased production by pituitary
  • idiopathic is most common (boys > girls)
    • also tumor, cranial radiation, familial short stature
    • usually normal length at birth
  • suspect if
    • 2-3 SD below mean of height for age
    • falling off growth curve
    • cross a percentile after 24 months
  • provocative testing, IGF-1 levels

258

how does radiation work?

  • uses penetrating ionizing beams of high energy targeted directly at cancer
  • goal is to kill cancer cells while limiting healthy cell damage

259

DI vs SIADH

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260

define retinoblastoma

  • rare eye cancer that develops in early childhood, typically before age 5
  • develops in retina (specialized light-sensitive tissue at back of eye that detects light and color)
  • usually only one eye (1/3 both eyes)
  • common first sign is cat's eye reflex (whiteness in pupil)
    • aka leukocoria 

261

cardiac physical exam - palpation

  • body
    • start distally and move centrally
    • 4 extremity pulses for strength and quality
    • skin temp - variations
    • suprasternal notch
  • precordium
    • PMI location
    • precordial activity
    • taps or thrills

262

aplastic crisis

  • when RBC destroyed, marrow needs to keep up
  • acute drop in Hgb may be r/t marrow failure
    • low reticulocyte (immature RBC)
  • parvovirus (fifth disease)
    • major cause
    • no immunization

263

SCFE nursing assessment

  • ABC
  • ortho-specific
    • difficulty walking, limp
    • knee, hip pain
    • hip stiffness
    • outward-turning leg
    • restricted hip movements
  • DEFG

264

postictal event

  • commonly amnesia
  • after the seizure
  • timing can vary, but usually same within one person
  • loftiness - no idea what happened, in a fog, out of it
  • can reply to questions, but it's difficult 

265

thalassemia definition

  • causes the body to make fewer healthy RBCs and less Hgb
  • two types
    • alpha
    • beta

266

respiratory complications from bedrest

  • less tidal volume
  • treatments:
    • spirometer, chest physio, cough/deep breathe
    • assess, pulse ox, vitals

267

DKA insulin Tx

resolve acidosis, suppress ketosis

  • regular insulin 0.1 unit/kg/hour IV (0.05 for younger)
    • IV allows quicker onset, smooth titration
    • initial bolus not required
      • may increase risk of hypoglycemia, hypokalemia
    • saturate insulin receptors

268

splenic sequestration

  • RBC get stuck in spleen
  • acute abdomen
  • "loss" of blood volume
  • splenectomy
    • immune issues
    • may be prophylactically necessary

269

taking history for tonic-clonic seizure

  • undressing - full assessment
  • medications
  • is this the typical seizure? same or different
  • vomit? incontinent of urine or stool?

270

platelets in ITP

  • low (500-1000)
    • takes 6 months to get back up to therapeutic level
  • at risk for bleeding
  • IgG - can decrease antibody production and help bone marrow rebound and start making more platelets
  • usually ~ 6 weeks for acute course to resolve
    • gamma-globulin and monitoring in the meantime 

271

airway assessment of liquid tumors

  • high % of WBCs and blast cells
    • marrow wants to make RBCs and platelets, but can't
  • low RBCs and platelets
  • can't carry oxygen 
    • tachypnic (b/c of anemia)

272

basic rules of cardiac physiology

  • blood takes path of least resistance
  • left sided heart pressures are higher than right sided heart pressures (in post-fetal hearts)
  • RV is not a systemic pump; physiologically differant than LV
  • blood flow in utero is necessary for development of distal structures and for extra uterine function

273

components of diabetes management

  • glucose monitoring
  • insulin
  • diet
  • exercise
  • emergency care
  • incorporation of diabetes into family life

274

cardiovascular complications from bed rest

  • circulation to extremities
  • clotting, DVT
  • stasis, decreased venous return
    • lower BP
    • lower CO

275

interventions for hydrocephalus

  • oxygen
  • pain
  • seizure precautions
    • safe enviornment, padded side rails, rails up, no clutter, oxygen, cardiac monitor, bed low
  • possibly diuretic, but not right away
    • depends on cause

276

diagnosing Kawasaki disease

  • no definitive lab or diagnostic test
  • based on CDC criteria and history
    • S/Sx
    • if one aneurysm, serial total body MRA (not just coronary arteries)
  • often a diagnosis of exclusion

277

hyperthyroidism overview

  • Graves Disease most common
    • autoimmune
    • adolescent females
    • hypersecretion of TH
  • often diagnosed due to school issues
    • mood swings, decreased attention, fidgety

278

pain and disability assessment during chemo

  • assess:
    • 90% complain of pain
    • long term pain after limb sparing surgery
      • phantom limb syndrome
    • what makes them feel better - advocacy
  • interventions:
    • pain assessment around the clock
    • IV PCA
    • epidural analgesia
    • local anesthetic wound catheters
    • continuous peripheral nerve block
    • sustained-release oxycodone
    • hypnosis, relaxation, guide imagery, acupuncture
    • benzos - anxiety

279

alpha thalassemia

  • especially in its alpha+ form
    • one gene non-functional
    • more widespread globally than B thalassemia
    • more than 50% of thalassemia population

280

drowning overview

  • distinct phases to drowning
    • pulmonary --> GI --> renal
  • public health issue - talk to families
  • most common cuase of death and permanent brain damage in school-age children and adolescents
  • younger child - only needs nose and mouth covered
  • older child - loses consciouness, mobility etc. that causes aspiration
  • most children who drown know how to swim but not with clothes on
  • only need to aspirate 2 ml for negative sequelae 

281

recurrent DKA: risk factors for admission

  • 15-20 yo
  • diagnosis in last 2-5 years
  • female
  • severe hypoglycemia episode in last year

282

left to right shunting

  • oxygenated
  • systemic to pulmonary circulation
  • body receives oxygenated blood
  • acyanotic

283

single ventricle physiology

  • presentation depends on fall of pulmonary vascular resistance and any obstruction to pulmonary blood flow
  • pulmonary and systemic venous congestion

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284

ventricular septal defect

  • flow shunts left to right
    • increased blood flow to right ventricle, out pulmonary valve, into pulmonary artery and into lungs
  • increased pulmonary blood flow
  • can cause hypertrophy of right ventricle 

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285

compliance

ability of the chambers to contract, relax, and distend during diastole

286

greenstick fracture

  • breaks like immature tree branch
  • broken on one side, bent on the other
  • children's bones are flexible and cartilaginous
  • treated with fiberglass cast, 6 weeks
    • reduced in ER

287

nursing teaching points for cerebral palsy

children with CP had high rates of slow growth and cognitive and motor impairment and re-hospitalizations in 18-22 months

288

fluid/electrolytes

  • dehydrated
  • electrolytes
    • low Hgb, Hct, MCV, mean corpuscular hemoglobin
    • high reticulocyte count (immature RBC)

289

S/Sx of increased intracranial pressure

  • confusion
  • amnesia
  • +/- headache
  • dizziness
  • ringing in ears
  • N/V
  • slurred speech
  • fatigue
  • retinal hemorraging (child abuse)
  • subdural hemorrhages

290

transitional cardiac physiology

  • at birth, oxygenation transitions from placenta to lungs
  • onset of spontaneous ventilation results in expansion of the alveoli
  • foramen ovale closes b/c of pressure change
    • causes rise in pulmonary blood flow
  • pulmonvary vascular resistance falls and pulmonary blood flow increases
    • causes rise in arterial oxygenation
  • combined with rise in system fascular resistance, changes to size/shape of cardiac chambers occurs 

291

afterload

systemi vascular resistance: workload the ventricles must overcome for systemic circulation, i.e. systemic pressure (BP)

292

fatigue assessment during chemo

  • multiple dimensions
    • cognitive, general, sleep, rest
  • constant verbal expression of the loss of energy
    • contiues at home, adolescents more so
  • are they playing normally?
  • issues with caregiver:
    • depression
    • divorce

293

what is the most important role of bones?

to provide for mineral exchange

294

variables that alter outcome for drowning

  • length of time
  • temp of water
    • cooler can preserve CNS better
  • response time
  • CPR initiation
  • should be admitted for at least 24 hours 

295

implications for continuous glucose monitoring

  • associated with lower HbA1c
    • especially in younger children
  • CGM users 
    • higher education
    • higher household income
    • private health insurance
    • longer duration of diagnosis
    • use of insulin pmp

296

SCD symptoms of heart

cardiomegaly, exercise intolerance

297

criteria for diabetic ketoacidosis

  • hyperglycemia: blood glucose > 200 mg/dl
  • metabolic acidosis: 
    • venous pH
    • plasma bicarb
    • anion gap - metabolic acidosis
  • hyperketosis and hyperosmolality
  • severity defined by degree of acidosis
  • 298

    types of sickle cell crises

    • vaso-occlusive - stuck in vessels
    • splenic sequestration - stuck in spleen
    • hemolytic - RBCs lysed
    • aplastic - RBCs not made

    299

    transposition of the great vessels

    • PA and Ao are transposed
      • PA from LV and Ao from RV
    • separate circulations
      • PDA is only communication usually
      • some communication through foramen ovale
    • deoxygenated blood bypasses lungs towards systemic circulation
      • infant is cyanotic
    • correction
      • moving the great vessels, but also need to move coronary arteries as well

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    300

    new evidence r/t DKA

    • presence of DKA at diagnosis associated with
      • delayed recall
      • decreased attention
      • possible IQ impact
    • impact of repeat DKA episodes??

    301

    cardiac exam: abdomen

    • contour
    • liver
      • size, location
      • start at hip bone and go up
    • spleen (palpable?)
    • ascites

    302

    cardiac physical exam - inspection

    • general appearance (+/- cyanosis)
    • posture
    • skin color - ashen
    • skin temperature - warm, cool?
    • respiratory rate, effort, positioning, use of accessory muscles
    • dilated veins - neck, abdomen
      • = red flag
    • carotid pulsations - visible?
    • check for PMI

    303

    kawasaki disease etiology

    • clinical features suggest
      • hypersensitivity reaction to environmental toxin or infectious agent
    • causative pathogens include:
      • mites
      • EBV
      • human herpes virus 6
      • retroviruses

    304

    cardiac cycle - coronary perfusion

    • coronary perfusion occurs during diastole
    • arteries come from base of aorta and supply 3-5% of blood flow to heart
    • if left ventricle can't contract enough, can't get systemic or coronary perfusion

    A image thumb
    305

    SIADH overview

    • syndrome of inappropriate antidiuretic hormone (secretion)
    • hypersecrete ADH
    • tumor, meningitis, neurosurgery, trauma

    306

    nursing interventions for Perthe

    • pain
    • x-ray, ultrasound, bone scan
    • brace teaching, crutches, post-op, rehabilitation 
    • evaluate home, provide guidance
    • encourage family participation
    • enable child to participate in normal activities
    • plans for continuing education
    • special activity arrangements
    • emotional support
    • encourage ROM exercises
    • bed rest to conserve energy

    307

    anemia where RBC is not made

    • bone marrow suppression (chemo)
    • no red blood cell precursors
    • malnutrition
    • thalassemia
    • post-strep glomerular nephritis
    • kidney problems

    308

    5 Ps of compartment syndrome

    • **pain out of proportion**
      • difficult to discern in child
    • pallor
    • pulselessness
    • parethesia
    • paralysis

    any one of these is suspicious 

    309

    changing profiles of pediatric epilepsy surgery candidates

    • communication conduits in brain
    • 90% of patients with surgery have achieved improvement in epilepsy severity and 74% are seizure-free since surgery
    • over time, interval to start of AED withdrawal shortened, resulting in significantly increased AED freedom at 2 years after surgery
      • goal is to not have to medically manage these patients

    310

    initial DKA epidemiology

    • 40% of children at initial presentation
      • delay in primary cause
      • difficult to get classic hx in young child
      • multiple caretakers, diapered child
    • 15% of hospitalizations 
    • most common presentation in diabetes in children
    • most frquent diabetes-related cause of death in children (
    • cerebral edema (primary)
    • multisystem organ failure

    311

    rule of 15's for hypoglycemic events

    • 15 grams carbs
    • recheck in 15 minutes
    • 15 more grams if needed

    312

    how does chemo work?

    • disrupts cell division
    • kills rapidly dividing cells

    313

    nursing interventions for ITP

    • NO PLATELETS
      • virus will continue to tag/attack them
    • teaching - low risk situation
    • come back frequently for platelet checks
    • helmets for younger children
    • assessing joints and joint discomforts
    • resolve more than 80% of time

    314

    GI/GU complications from bedrest

    • higher risk for UTIs
      • catheter
      • no gravity, not hydrated
    • slowed peristalsis, constipation

    315

    risk factors for drowning

    • age (youth)
      • peaks at 2 and then at 16-18
    • location (pools, bathtubs)
    • sex: male 3:1
    • drugs
    • trauma
    • predisposing illnesses (epilepsy)
    • warm weather months

    316

    cast care

    • neurovascular status
    • vital signs
    • smells, drainage
    • avoid lotions, powders
    • avoid affected extremity in dependent position
    • protect edges if child is incontinent 

    317

    DKA management recommendations

    • cardiac
      • high frequency of prolonged QT interval
    • O2 if indicated for shock
    • 2 IVs
      • one for blood sampling (glucose)
      • avoid central lines
        • increased risk for thrombosis r/t dehydration
    • hourly VS, neuro, I&Os, blood glucose
    • VBG, electrolytes q 2-4 hours
    • BUN, Cr, Hct q 6-8 hrs
    • urine ketones until cleared

    318

    nursing assessments for hip dysplasia for child who can walk

    • waddling, limping
    • one shorter leg, so walk on toes on one side
    • lower back is rounded inward

    319

    nursing assessments for osteomyelitis

    • vital signs, febrile
    • bone pain, swelling of affected area, pain
    • localized pain, febrile, able to ambulate or perform pasive ROM
    • normally have full ROM in joints because joint is not affected
    • tender to the touch

    320

    normal cardiac anatomy and blood flow

    A image thumb
    321

    nursing assessment for wilms tumor

    • abdominal exam
      • often asymptomatic mass
    • pain
    • hematuria
    • hypertension

    322

    fetal circulation

    • 1 vein from placenta
    • fetal arterial oxygen tension is decreased
    • tolerate decreased oxygen (hypoxemia) due to increased CO and high fetal Hgb
    • ~ 2/3 blood flows to brain, coronary arteries, descending Ao
    • fetal lungs are collapsed: PVR > SVR
    • PVR high in fetus and starts to fall after the 1st week of life
    • returns to placenta via 2 arteries

    323

    incidence of osteosarcoma

    • 4.5 million males, 3 million females (2x more males)
    • 4th most common cancer
    • 80% in femur or tibia

    324

    cerebral palsy definition

    • dx of movement, muscle tone (conduction), or posture caused by insult to immature, developing brain
      • ischemic or anoxic event
      • cell death - as if child had stroke 
    • most often before birth
    • effect on functional abilities varies greatly
    • generally does not worsen, except if degenerative from clots (more anoxic events)

    325

    treating hydrocephalus

    • diagnosed by ultrasound
    • treated with ventriculoperitoneal (VP) shunt, ventriculostomy, VA shunt (into pleural space of heart - could increase risk of heart failure)
      • can also shunt into bladder
    • complications
      • mechanical
      • infection
      • herniated brainstem

    326

    ataxic cerebral palsy

    • characterized by ataxic movements and speech
    • widespread disorders of motor function 

    327

    SCD symptoms of kidneys

    • ischemia of kidneys
      • enuresis
      • hematuria
      • inability to concentrate urine
    • chronic renal failure

    328

    aspirin for Kawasaki disease

    • decrease inflammation
    • inhibit platelet aggregation
    • decrease venous stasis and thrombus formation
    • at risk for:
      • bleeding, seizures
      • Reye's syndrome
      • platelet dysfunction (bleeding anywhere in body)

    329

    presentation of coarctation of aorta: neonates

    • dependent on PDA for blood flow down aorta 
    • present in shock due to PDA closure
    • marked difference in BP between UE and LE
    • may be unable to palpate LE pulses

    330

    diabetes education topics

    • activity
    • coping
    • monitoring
    • medications
    • nutrition
    • problem solving
    • risk control
    • endocrinologist, NP, psychologist, dietician, diabetic nurse educator - 3 months to feel in control (9 w/ pump)

    331

    osteomyelitis etiology

    • usually caused by bacteria, but also by fungi or other
    • may spread to bone from infected skin, muscles, tendons
      • can occur under a skin sore
    • can start in another part of body and spread to bone through blood
    • can start after bone surgery, especially with metal rods or plates
    • in children, long bones of arms or legs most often involved
    • in adults, feet, spine, and hips most affected

    332

    common risk factors for cerebral edema r/t DKA

    • elevated BUN
    • profound hypocapnia at presentation
    • bicarb administration

    333

    epilepsy

    • disorder in which seizures recur because of a chronic underlying pathology that invariably is initiated in the CNS
    • no identifiable causes in 50% of cases
    • other causes:
      • genetic
      • trauma
      • tumor
      • infectious disese (meningitis, syphilis)
      • prenatal injury

    334

    risk factors for DKA at initial presentation

    • lack of private health insurance
    • lower SES
    • misdiagnosis

    335

    cardiac physical exam - auscultation

    heart sounds

    • S1 - closing of tricuspid & mitral valves; ventricular contraction
      • single heart sound
      • apex/mitral; tricuspid
    • S2 - closing of pulmonary and aortic valves
      • RR influences timing of valve closure
      • usually a single sound, can be heard as 2 sounds (split S2)
      • aortic; pulmonic

    336

    glucose in DKA

    • hyperglycemic
    • fluid pulled from extravascular to intravascular space
    • Na diluted due to increased intravascular fluid
    • correction formula for Na during DKA episode

    337

    7 basic treatment goals of DKA

    • restore extracellualr volume at moderate, reasonable pace
    • restore intravascular volume
      • improve perfusion
    • gradually decrease effective plasma osmolality
      • otherwise, neurological problems
    • stop ketogenesis
    • correct electrolyte disturbances
    • avoid complications
    • individualize therapy

    338

    side effects of chemo

    • N/V/D/C
    • sterility
    • mucositis
    • neuropathy
    • alopecia
    • bone marrow suppression
    • carcinogenic 
    • photosensitivity
    • cardiotoxic 

    339

    anion gap

    • difference between measured cations and anions
    • nmeasured anions (phosphate, sulfate, protein) account for gap
    • normal = 10-14
    • Na - (Cl + HCO3)
      • 139 - (113 + 4) = 22

    340

    S/Sx of cerebral palsy

    • motor tone, orthopedic dx
    • urinary dx
    • reflexes
    • still muscles with normal reflexes (rigidity)
    • stiff muscles with exaggerated reflexes (spasticity)
    • lack of muscle coordination (ataxia)
    • seizures
    • not meeting developmental milestones
    • eating issues, oral pharyngeal
    • difficulty grasping
    • vision, hearing, speech
    • pain - often can't communicate

    341

    alopecia

    hair loss - be sensitive to patient and family

    342

    idiopathic thrombocytopenic pupura

    • ~5/100,000 with peak age of 5
    • aka autoimmune thrombocytopenic purpura 
    • destruction of platelets in spleen
    • follows a virus
    • autoantibodies bind to platelet antigens 
      • actual production of platelets in the spleen is fine
    • platelets foreign for the duration of the virus

    343

    differentiate between ITP and trauma

    • pain
    • swelling
    • talk to the family
      • viral illness
      • no trauma

    344

    beta thalassemia

    • three main forms
      • thalassemia major/Cooleys (most common)
      • thalassemia intermedia
      • thalassemia minor
    • thalassemia major
      • present within first two years of life with severe anemia requiring regular RBC transfusions
      • growth retardation, pallor, jaundice, poor musculature in poorly transfused or untreated individuals 

    345

    effective osmolality in DKA

    • high glucose level, dehydration increase osmolality
    • calculated as
      • 2 X (Na + K) +[(glucose mg/dL)/18]
    • normal osmolality = 300

    346

    airway assessment for SCD

    • tachypnea
    • low pulse ox

    347

    trabeculum

    • mineral metabolism
    • honeycomb - where blood is stored
    • osteoblast and osteoclast activity

    348

    hypertrophic cardiomyopathy: overview

    • increased myocardial mass, especially LV
    • decreased ventricular cavity size
    • blood flow obstructed
      • hypertrophic tissue
      • left ventricular outflow tract obstruction
    • big, thick, ugly heart
    • decreased preload, contractility, and CO

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    349

    3-2-1 rule of DKA

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    350

    suspect CHD when

    • murmur AND cyanosis
    • cyanosis WITHOUT respiratory distress
    • crying WORSENS cyanosis
    • abnormal WEIGHT LOSS, poor weight gain, feeding w. tachypnea, diaphoretic with feeding
    • DISCORDANT UE/LE pulses
    • infants appear SEPTIC
    • diangosed with a SYNDROME
      • many syndromes go hand in hand with cardiac defects

    351

    nursing assessments for hip dysplasia in newborn

    • leg with hip problem may turn out more
    • reduced movement on that side of the body
      • Ortolani-Barlow test
    • shorter leg on that side
    • uneven skin folds of thigh or buttocks
    • after 3 mo, leg may turn out or be shorter

    352

    enoxaparin for Kawasaki disease

    for aneurysms 

    353

    causes of hydrocephalus

    • congenital
      • neural tube defects, infection, hemorrhage, genetic defects, teratogens, Chiari malformations, Dandy-Walker malformation
    • acquired
      • infections, tumors 

    354

    contractility

    strenght of the squeeze of the cardiac muscle

    355

    bone physiology

    3 tasks, 3 areas

    1. cortex
    2. canal
    3. trabeculum

    356

    pump + CGM benefits

    • lifestyle flexibility
      • birthday parties, social activities
    • school safety
    • improved sleep
    • increased self-efficacy
    • young child
      • fewer mealtime behavior issues

    357

    antiepileptic drugs (AEDs)

    • levetiracetam (Keppra)
    • carbamazepine (Tegretol)
    • phenobarbital
    • phenytoin (Dilantin/Fosphenytoin)
    • valproate (Depakote)

    358

    diagnosing DKA without access to venous pH testing

    • bicarb alone

    359

    family teaching for febrile seizures

    • may happen again
    • do they give them motrin or tylenol? how much, how often?
    • thermometer?
    • give family one valium suppository
      • nothing PO
    • should not last more than 4 minutes
    • time the seizures
      • more than 5 min = status epilepticus 

    360

    nursing interventions for hip dysplasia

    • pavlik harniss
      • flexion and abduction (less than 6 mo)
    • spica cast (older than 6 mo)
    • surgery, casting, bracing (older than 18 mo)

    361

    dilated cardiomyopathy: treatment

    • positive inotropic agents - slow/strengthen heart contractility
    • diuretics - decrease afterload
    • vasodilators - decrease systemic vascular resistance to reduce workload
      • but still need venous return
    • afterload reduction - take away workload on heart
    • prioritize perfusion of brain, heart, lungs

    362

    primary symptoms of Kawasaki disease

    • fever > 5 days
    • erythema of palms and soles with indurative edema (peeling)
    • rash - polymorphous exanthema; peeling
    • strawberry tongue, red lips
    • bilateral conjunctival congestion
      • sometimes first S/Sx
    • cerical lympadenopathy

    A image thumb
    363

    GI/GU/musculosketal assessment for SCD

    • bowel sounds
    • some present in crisis in joints
    • ROM test

    364

    coup

    point of impact of TBI

    365

    why is there long-term impairment in brain tumors?

    • brain growing and developing
    • misdiagnosis/undetected for a long time
    • can't always get rid of it
      • maybe if it's encapsulated 

    366

    potassium in DKA

    • K moves out of cell d/t decreased insulin concentration, acidosis
    • total body K is depleted
    • with Tx, serum K will rapidly decrease as addition of insulin and correction of acidosis drives K intracellular

    367

    causes of hip dysplasia

    unknown. low levels of amniotic fluid may increase risk

    368

    DKA: two bag system

    • two identical fluid bags MINUS dextrose content
      • A: 0.45-.9% saline with 20 meq/L K Phos or 20 meq/L KCL or k acetate
      • B: D10 0.45-9% saline with 20 meq/L k Phos or 20 meq/L KCl or K acetate
    • before starting K, ensure renal fxn, K
    • replace depleted phosphate (why K phos is more common)
  • facilitates efficiency, timeliness, flexibility
    • can go back and forth easily, if you overshoot the mark
  • A image thumb
    369

    early indicators of cerebral edema

    • age inappropriate incontinence
    • HR decrease of 20 bpm or more NOT attributable to
      • improved intravascular volume status
      • sleep
    • altered LOC
    • lower pH, younger age are ONLY independent predictors of decreased LOC

    370

    PICU should be considered in cases of DKA when:

    • severe DKA
    • decreased LOC
    • shock
    • children at risk for cerebral edema
      • low pH
      • low total CO2 (shows extreme "mixed" acidosis with respiratory and metabolic components)
      • high BUN

    371

    circulation assessment for SCD

    • tachycardic - low iron
    • decreased peripheral pulses
    • cardiac issues in general from low baseline oxygenation
      • enlarged valves from compensation for low oxygen levels

    372

    distal humerus (supracondyler) fracture

    • common b/c put in propeller-type motion to catch themselves on ground
    • lot of nerves in that area
      • neurovascular check
      • periphral pulses, skin appearance, moving extremities, sensation
    • maintain circulation, perfusion
    • localized edema
      • RICE
      • pain meds

    373

    causes of TBI

    • bump, blow, jolt to head or penetrating injury that disrupts normal fxn of brain
    • not all blow or jolts result in TBI
    • severity ranges from:
      • mild: brief change in mental status or consciousness
      • severe: extended period of unconsciousness or amnesia

    374

    DKA presentation

    • polyuria, polydipsia
    • weight loss
    • abdominal pain
    • nausea and vomiting
    • abdominal tenderness, decreased bowel sounds
      • ileus d/t acidosis, decreased K (muscle fxn), decreased gut perfusion
    • tachycardia
    • decreased peripheral perfusion
    • tachypnea (response to metabolic acidosis)

    375

    nursing interventions for hemophilia

    • IF neuro is clear, very focused
    • treat joint/area - factor
    • peripheral pulses
    • ROM
    • monitor for compartment syndrome
      • pain out of proportion

    376

    SIADH teaching

    • sources of fluid
      • popsicles, jello, medications
      • odd places thirsty children will find fluid

    377

    treatments for chemo-related N/V

    • relaxation
    • antiemetics before chemo
    • first gen 5-HT receptor antagonists
      • Palonosetron (Aloxi), Ondestetron
    • NK1 antagonists - Aprepitat
      • different rxn than 1st gen
    • corticosteroids
    • benzodiazepine
    • other strategies + support team

    378

    side effects of AEDs

    • CNS active drug - can affect all aspects of brain
      • sedation, hyperacticity, increased/decreased appetite, mood changes)
    • leech calcium by increasing percentage of osteoclasts
      • most mineral exchange in hips and spine 
    • unique side effects:
      • dilantin: hirsuitism, gum hypertrophy
      • lamictal: Steven Johnson rash
      • benzos: sedation, memory storage
      • depakote: hepatotoxicity, pancreatitis, decreased platelets, neural tube defects (menarchal - folic acid)

    379

    familial hypercholesterolemia overview

    • autosomal dominant
      • defect on chromosome 19
    • defective clearance of LDL cholerstol
      • risk for atherosclerosis
    • prevlance ranges from 1 in 200-500
    • increasing occurence in children

    380

    brain tumor definition

    • neoplasms
    • most common solid tumors in children and adolescents
    • significant long-term impairment to intellectual and neurological function is possible
    • life threatening if not treated promptly

    381

    hemoglobin S

    • causes RBC to sickle and not flow through capillaries
    • changes in appearance often randomly

    382

    signs and symptoms of congestive heart failure (CHF)

    • tachypnea, wheeze, crackles
    • increased WOB, retractions, grunt, cough
    • Hx of frequent respiratory infections
    • tachycardia, decreased pulses, hypotension, > 3 sec cap refill
    • exercise/activity intolerance
      • rest periods during feeds - red flag for families
    • poor weight gain, growth failure
    • diaphoresis, cool extremities
    • frequent emesis - swallowing air
    • irritable

    383

    aplastic anemia defined

    • blood dx in which body's bone marrow doesn't make enough new blood cells
    • makes stem cells that develop into RBC, WBC, platelets

    384

    diabetes insipidus signs and symptoms

    • extrem thirst
    • huge urine output
    • new onset bedwetting

    385

    rare DKA complications

    • cerebral edema (biggest implication)
    • pulmonary edema
    • CNS hemorrhage/thrombosis
    • large vessel thrombosis
    • cardiac arrhythmias
    • pancreatitis
    • renal failure
    • intestinal necrosis
    • rhinocerebral & pulmonary mucormycosis (rare fungal infection)

    386

    social support during chemo

    • child life
    • social work
    • anticipatory guidance
    • school

    387

    Hodgkin's lymphoma

    • nontender, firm lymphadenopathy
      • supraclavicular and cervical nodes and in mediastinal area
      • worrisome:
        • 2+ supraclavicular nodes that are long-standing
        • supraclavicular nodes > 2mm
        • femoral/inguinal nodes that are long-standing and more than 15 mm
    • lymph node biopsy reveals Reed-Sternberg cells
      • classic cell differentiation from non-Hodgkin's
    • staging of disease

    388

    SIADH signs

    • low urine output, sodium, osmolality
    • high urine osmolality
    • seizures, altered mental status

    389

    diabetes survival skills

    • initial hospitalization 2-3 days
    • teach information needed to be safe
      • basic pathophysiology
      • psychomotor skills
        • insulin injection
        • BG meter use
      • hypoglycemia reognition and treatment
      • calculation skills

    390

    nursing interventions for SCD

    • OXYGEN - low Hgb, not oxygenating tissues
    • IV
      • pain meds
      • labs (CBC with differential, type and cross for transfusion, sickledex, potassium, bilirubin)
    • blood transfusion
    • cardiac monitor
    • I&Os, bowel sounds
    • skin assessment
    • ask family
      • what works? distraction, massage, heat packs

    391

    osteomyelitis definition

    • bone infection caused by bacteria, other germs
    • more localized, not septic
      • tender, sore, swollen, low fever, hx of previous infection maybe
    • home care with PICC line for 6 weeks

    392

    recurrent DKA epidemiology

    • 5% per year
    • insulin omission = primary cause
      • adolescents = primary group at risk
    • illness
      • need sick day plan
    • infection
    • pump malfunction

    393

    SCFE definition

    slipped capital femoral epiphysis is a separation of the ball of the hip joint from the thigh bone (femur) at the upper growing end (growth plate) of the bone

    394

    diagnostic testing for child experiencing seizures

    • MRI
    • CT
    • lumbar puncture
    • labs
    • EEG
    • nurses can help/prepare child 

    395

    nursing assessment for child who experiences drowning

    safety, teaching, prevention

    5 ft fences on all sides of pool, trained CPR guards

    396

    multifactorial process of diabetes

    A image thumb
    397

    Ewing's sarcoma

    • can occur anytime in childhood or young adulthood
    • usually during puberty when bones growing rapidly
    • 10X as common in caucasians as African-American, African, Asian children
    • long bones, pelvis, chest, skull or flat bones

    398

    pulmonary valve stenosis or atresia

    • right to left shunt between ventricles
    • abnormality/absent pulmonary valve
    • deoxygenated blood moves from right to left and into systemic circulation
    • constriction at pulmonary artery so blood and pressure builds up in right ventricle
      • can't go through valve, so will go through hole (SVD)

    A image thumb
    399

    SCD symptoms of penis

    microcirculatory obstruction and engorgement of penis (priapism)

    400

    nursing treatment for SCD patients at home

    • prophylactic antibiotics - PO penicillin VK
    • parental education and compliance
    • folic acid daily
    • hydration
    • strict hand-washing
      • infection control

    401

    SCD symptoms of bones

    • chronic ieschemia of bones leads to susceptibility to infection and bone degeneration
    • osteoporosis, osteomyelitis
    • spinal deformitis
    • aseptic necrosos of the femoral head, gait abnormality

     

    402

    cardiac cycle

    A image thumb
    403

    if DKA acidosis does not correct

    • inadquate insulin infusion
      • or IV not patent
    • inadequate rehydration
    • renal failure
      • increased risk with time
    • sepsis

    404

    hip dysplasia definition

    developmental dysplasia of the hip (DDH) is a dislocation at birth because hip socket does not develop properly

    found in babies and young children

    405

    cardiomyopathy: clinical manifestations

    • cardiomegaly on CXR
    • symptoms: asymptomatic initially
      • murmur
      • poor perfusion
      • CHF
      • low CO
        • decreased urinary output, alteration in LOC, syncope, thromboembolic events, arrythmias

    406

    increased pulmonary blood flow

    • left sided pressures > right sided pressures
    • most blood shunts left to right
    • first 3 months, PVR decreases and SVR increases
    • presumed hypermetabolic state
      • don't gain weight or feed well - need a lot of calories
    • increased pulmonary blood flow causes tachypnea to breathe through all the circulation
    • more likely to cause CHF

    407

    cyanotic lesions

    • mostly during neonatal period
    • fail hyperoxia test 
    • dependent on PDA
    • monitor for PGE1 side effects
    • presentation varies depending on degree of abnormality
    • requires intervention immediatley after birth

    408

    seizure definition

    • sudden abnormal electrical discharge from neurons within the cerebral cortex that produces a disturbance in behavior, sensation or motor function
    • an een that may be initiated by either a CNS process, such as a head injury or lead poisoning, or a process external to the central nervous system such as fever, drug withdrawal, electroconvulsive therapy

    409

    gold standard diagnostic tool for liquid tumors

    bone marrow biopsy

    410

    assessment of skin/derm during chemo

    • assess: PO, oral hygiene
    • Interventions:
      • dental care - soft brush
      • miracle mouth wash with lidocaine
      • oral exam with light
      • oral medications to prevent breakdown
        • IV narcotics, pain management
      • start oral care BEFORE ulceration occurs so they know it's part of their care 
        • b/c they won't like it
    • ulcerations can go all the way down to the rectum

    411

    define sickle cell disease

    • group of inherited RBC disorders
    • abnormal hemoglobin
      • hemoglobin S or sickle hemoglobin in RBCs
    • two abnormal hemoglobin genes
      • in all cases, one of two abnormal genes causes hemoglobin S
      • two genes = hemoglobin SS (sickle cell anemia)
    • most common and severe kind is SCD

    412

    vaso-occlusive sickle cell crisis

    • sickled cells get stuck
    • blood flow impeded
      • generalized or local or in lungs (acute chest)
    • cells starve
      • pain from ischemia - lack of oxygen r/t obstruction
      • death 
        • avascular necrosis
        • CVA
      • acute chest
    • heat packs can help 
    • X-ray or MRI to rule out septic arthritis 

    413

    nursing interventions for thalassemia

    • similar to sickle cell
    • + transfuion and accompanying meds to bring down iron
    • relevant to nursing = transfusion reaction

    414

    seizures and injury

    • more fractures
    • more thermal injuries
    • twice risk of poisonings (medicinal)
    • NURSING TEACHING POINT

    415

    hyperglycemic hyperosmolar syndrome

    • aka hyperglycemic hyperosmolar non-ketotic syndrome
    • people at risk
      • children with T2DM
      • adolescents

    416

    recommendations for Tx of cerebral edema

    • ensure adequate mean arterial pressure to ensure adequate cerebral perfusion pressure
      • autoregulation may be impaired due to hyperemia and vasogenic edema
    • avoid hyperventilation, hypercapnia
    • mannitol or 3% saline 

    417

    components of palliative care

    • quality of life
    • pain and symptom management
    • communication
    • ethical decision making
    • advance care planning
    • grief and bereavement
    • spiritual and religious needs
    • body language and honesty
    • availability and attentiveness among nurses and doctors