final review Flashcards
1
Q
burns - abuse
A
soles of feet, palms, back or buttocks
pattern burns, irons, heater grates, cigarettes, rope burns
non accidental immersion: clear delineation, contiguous with sparing in flexion creases, no splash marks
when they look like something
2
Q
bruise
A
1 sign!!
shadow: same same as instrument used to inflict
rule of TEN: torso (seatbelt, handlebar), ears, and neck (petechiae, check tracheal damage) difficult to bruise <4yr
scalp bruises indicate abuse
don’t confuse with mongolian spot - blue/grey
ok spots: forehead, forearms, knees, ankles
bad spots: btw eyes, ears, coccyx, upper back btw shoulders, calves, back of thighs, front of thighs, genetalia
3
Q
behavior characteristics of abused children
A
wary of adults, vacant stare or always watchful, overly compliant, passive, or withdrawn - little movement or crying with painful procedures; doesnt turn to parent for support, constantly trying to please and assess parental reaction, role reversal, aggressive towards animals or smaller children, sudden change in behavior or school performance, learning problems or issues concentrating not attributed to physical or psychological causes, come to school/activities early and doesnt want to leave
4
Q
consider neglect when child…
A
freq absent from school
begs or steals food/money
lacks needed medical care
consistently dirty
lacks sufficient clothing for weather
abuses drugs
states no one is at home to provide care
5
Q
role of RN
A
dont promise not to tell!
promise to keep them safe
have to report
prevent, recognize, report
6
Q
fractures of abuse
A
unexplained, different healing stages
scapular fracture without clear history
epiphyseal and metaphyseal fractures of long bones
spiral fractures
dislocations - shoulders or hips
7
Q
how to talk to abused children
A
play therapy for disclosure
8
Q
how to help crying child
A
hospital based programs, educate on period of purple crying
5 S’s: shushing, side/stomach (w/ supervision), sucking, swaddling, swinging
9
Q
burns - immersion/accidental
A
irregularly shaped, splash marks, depth of burn decreases as distance increases from point of major contact, flow marks proceed downward
10
Q
consider neglect when the parent…
A
indifferent to child
apathetic or depressed
behaves irrationally or bizarrely
abusing drugs
11
Q
fam/env factors of abuse
A
domestic violence, isolation, poverty/limited resources, unemployment, single parent, animal abuse, increased exposure btw parent and child, major life changes
12
Q
parental characteristics of abused
A
substance use, low self esteem, poor impulse control, abused as child, teenage parent, negative view of child, depressed, unrealistic expectations of child, corporal punishment
male, <30 yrs, educated less than high school, illiterate, social isolation
13
Q
risk factors of child
A
anything that increases stress of caring for child, cries a lot
altered bonding process
hyperactivity/perceived defiance
resemblance to abusive ex
prolonged/chronic illness, special needs, medically fragile, dev delays, NAS, premature
colic
multiple births
male
14
Q
warning signs of abuse
A
physical evidence - including previous injuries
no history to explain findings
injury not consistent with history or dev level
delay in seeking med attention
history changes with repetition, conflicting stories
blame child or sibling
seek med attention far from home
reaction to injury is inappropriate
15
Q
behavioral characteristics of abusive parents
A
show little concern for child
denies existence of or blames child for problems in school or at home
asks teachers or other caregivers to use harsh punishment
sees child as entirely bad, worthless, or burdensome
demands level of physical or academic performance the child cannot achieve
looks primarily to child for care, attention, and satisfaction of emotional needs
16
Q
physical indicators of abuse
A
bruises, welts, lacerations, abrasions, broken bones
various stages of healing and atypical areas
clustered, regular pattern, teeth marks, handprint
shadow bruises
17
Q
s/s of PAHT
A
seizures, posturing, unequal pupils, high pitch cry, retinal hemorrhage, pale, mottled, cold, clammy skin, poor feed, bruise, vomit, change in LOC, decrease in smile or vocalizing, behavior change, vision loss, change in head control, bradypnea or apnea, bradycardia, bulging fontanelle
scalp bruises, traumatic alopecia, black eyes, fractures
18
Q
perpetrator characteristics
A
male, <30 yrs, educated less than high school, illiterate, depressed, social isolation, substance abuse, low self esteem, poor impulse control
19
Q
how to help parents with crying child
A
hospital based programs, take a break, put as many doors between you and the child
20
Q
munchausen syndrome by proxy (MSP)
A
illness that one person fabricates or induces in another person
21
Q
MSP - child characteristics
A
<6, uncooperative, anx, fearful, negative
22
Q
MSP - perpetrator characteristics
A
mom, thrives in healthcare env, some health care knowledge, loving, cooperative, competent, suggests tests and procedures
23
Q
MSP - when to suspect
A
unexplained prolonged, recurrent, extremely rare
discrepancies btw findings and history
unresponsive to treatment, s/s only in parent’s presence
knowledgeable parent, refuses to leave child’s room
parent very interested in interacting with med staff
fam members with similar symptoms
24
Q
diaper dermatitis (rash)
A
erythema on thighs, butt, perineum, waist, lower abd
creases spared
25
diaper dermatitis (rash) - nc
dry affected area and prevent contact with irritant (baby wipes dry out, 4x4 with NS)
change wet diapers immediately
occlusive ointments (zinc oxide or petroleum)
wash off feces with water and mild soap
expose slightly irritated skin to air
26
diaper dermatitis - candida albicans
thrush
treat with antifungal nystatin
27
poison ivy
redness, swelling, itch at sight of contact, advances to streaked or spotty blisters
flush area immediately after contact with cold running water
wash clothing and pets
scratch doesnt spread but can cause secondary infection
benadryl at home
if on face - come to DR bc need oral steroid
28
impetigo
highly contagious
macular rash progresses to papular vesicular rash that oozes and forms moist honey colored crust
29
impetigo - tm
soften and remove crusts then apply topical bactericidal ointment
oral abx
contact precautions - school >24 hrs post abx, HH, dont share towels/linens, cover lesions
cut nails short, cover hands at night
30
varicella cm
slight fever, malaise, anorexia, pruritic rash
31
varicella nc
strict isolation: communicable one day before rash -> all lesions crusted over
vaccine (12 mo, 4yr)
VZIG
no aspirin
teach good skin care
32
tinea - nc
emphasize good health and hygiene
examine household pets
teach children not to share hats, scarves, helmets, etc
33
pediculosis (lice) - educate
avoid shampoo rinse contact with eyes, dont treat in tub or shower, apply only to infected area, wash bedding, clothes in hot water and dry in hot dryer (20 min), comb out nits with fine tooth comb, soak brushes and combs or dishwasher sterilization, store unwashables in sealed plastic for 2 weeks or freezer overnight)
34
pediculosis (lice) - tm
nix creme rinse 10 min or permethrin shampoo to DRY hair for 10 min
35
tick bites - first aid
not poisonous but can transmit disease
remove with tweezers close to skin, gently pull until it lets go
wash with soap and water
antiseptic on site and apply abx cream if not allergic
med attention if rash appears or flu like S
36
tick bites - prevent
mowed lawns, clean up brush, stack wood piles
wear socks, suck long pants into socks
wear light colored clothes
dont lay clothing, towels, etc on ground
walk in middle of paths
comb through hair
check everywhere
37
give meds to reluctant toddler
guided choices, praise, security object
38
give meds to reluctant preschooler
give choice, mix with food, reward, change method of delivery
"lets do this" "how about"
allow transitional object
39
infant toys
mobiles, rattles, squeaking toys, picture books, balls, colored blocks, activity boxes, unbreakable mirror, music box, cuddly/soft toys, teethers
security object, peek a book, mirror, pots and pans, stack/nest toys, large ball
40
toddler toys
board and mallet, push-pull toys, toy telephone, stuffed animals, story books with pictures, rhymes, paper to scribble, blocks to stack, large boxes, simple puzzles
41
preschooler toys
coloring books, puzzles, cut and paste, dolls, building blocks
dress up, brooms, vacuum, hammers, saws
42
preschooler play
associative: group play without rigid organization
cooperative play: imaginative and imitative (adults)
43
preschooler language
>2100 words by 5 yr
3-4 word sentences by 3-4 yrs
4-5 yrs = adverbs, adjectives, verb variety
5 yrs = all parts of speech
classify
share and listen to stories
44
school agers play
team or group - conformity and ritual, want to be with their peers, more structured, fairness but will cheat, competition
table games, boys and girls separate
45
adolescent play
increase reading and lang skills, body image, rapid and marked physical growth
46
infant play - 0-3 mo
not differentiated, smile and squeal
47
infant play - 3-6 mo
lol at 4 mo
sensory stim, learn to distinguish self from env
solitary play
short periods, parents can talk, sing, laugh, read
48
infant lang dev
cry 1 - 1.5 hr/day up to 3 wk
cry 2 - 4 hr/day up to 6 wk - then decrease
end of 1 yr = specific cry for wants
5-6 wk = vocalization, coo
3-4 mo = consonant, lol
5-7 mo = vowel
8 mo = imitate sounds, combine syllables
9-10 mo = simple commands and "no"
12 mo = 3-5 words with meaning besides mama and dada
49
toddler lang dev
2 yr = 300 words, multiword sentences
~65% understandable by 3 yrs
50
toddler play
parallel play
imitation play - trucks, dress up, dishes, cleaning
51
coarctation of aorta
narrowing of aortic arch causing increased blood flow and P to UE, and decreased blood flow and P to LE
L -> R shunt
52
coarctation of aorta tm
prostaglandin E
balloon angioplasty
sx w/n 2yr
53
digoxin admin
contract harder (decrease HR), oral
regular intervals, 1 hr before or 2 hrs after eating, dont mix, behind teeth or brush, missed dose <4 hr give, dont give if >4 hr, call hcp if 2 missed, dont repeat if v
preassessment: check K (dont give if low), hold if apical rate is <90 in infants and <70 in older kids
54
digoxin toxicity
n, v, bradycardia, anorexia, neuro and visual disturbances (blurry, seeing doulbe), monitor for dysrhythmia, digibind (watch K)
55
tetralogy of fallot
pulmonic stenosis, overriding aorta, VSD, right ventricular hypertrophy
56
tet spells
CALM, knee chest, 100% O2, morphine, iv fluid replacement, morphine
57
cath lab pre op
npo (morning meds?, 4-5 hrs before)
IV fluids?
dev appropriate prep
sedation?
mark pedal pulses
height and weight - cath length and SDR
no diaper rash
58
cath lab post op
lie flat for several hours, prep for this before - what are they going to do to pass the time
color and LOC, VS (q15 then 1 hr) and resp status
pules distal to site can be weaker for first few hours, dressing for bleeding (P 1" above sight, circle, call for help), fluid intake, hypogly (dextrose in IV)
59
cath lab discharge
pressure dressing x24 hr, no tub bath 48 hr, rest that night then normal activities, teach s/s of infection
60
transposition of the great arteries tm
prostaglandin E and/or balloon atrial septostomy
61
cyanotic defects nc
alteration in oxygenation, anx, dehydration, prevent and accurate assessment of resp infection
good skin care, supplement oxygen, monitor for and prevent dehydration, dev appropriate prep for tests and procedures
62
chf cm
heart doesnt supply body's needs
tachypnea, wheeze, crackles, retractions, cough, dyspnea on exertion, grunt, nasal flare, cyanosis, feeding difficulties, irritable, fatigue with play
hepatomegaly, ascites, edema, weight gain, neck vein distention
high met rate
impaired myocardial function
63
chf tm
improve cardiac function, remove accumulated fluid and Na, decrease demands, improve tissue oxygenation and decreased oxygen consumption
64
chf nc - activity intol
promote rest, prevent cry, group activities, short play, cuddle, neutral thermal env, supplemental O2 (not always, based on normal)
65
chf nc - altered nutrition
anticipate hunger, small and freq, feed no longer than 30 min - ng, feed in relaxed env, semi erect position (dont swallow air), burp freq, formula with increased cal, soft premie nipple with mod large opening
66
chf nc - ineffective breathing pattern
assess RR, effort, and o2 sat
position for max chest expansion
avoid constriction
humidified supplemental o2 - during stressfull periods (cry, invasive procedures)
67
chf nc - infection
avoid crowded public places
good hand washing
screen visitors
68
chf nc - fluid volume excess
accurate I+O, weigh daily (same time, scale, clothes), assess for edema, maintain restriction, good skin care, change position freq
69
chf nc - fam educate
teach s/s of worsening clinical status
how to give meds - digoxin
importance of good nutrition (high cal req and tire easily)
UTD on immunizations, need RSV if <2yr
promote G+D
70
bacterial endocarditis (BE)
inflam process from infection of valves and inner lining of heart
rf: chd or acquired, dental procedures, sx, intracardiac lines
strep or staph, or fungi
71
BE cm
low grade intermittent fever, anorexia, malaise, weight loss, joint pain, + blood culture, new heart murmur or change in existing, petechiae of mucous membranes, janeway spots, osler nodes, splinter hemorrhages under nails
72
BE tm
IV abx 2-8 wk
sx removal of emboli and/or valve replacement
prevent - prophylactic abx 1 hr before risky procedures
73
BE nc
teach prophylactic abx and how to give at home
relieve S - painful joints
monitor for emboli
74
kawasaki cm - acute
acute systemic vasculitis
8-10 days
fever (unresponsive to antipyretics, 5+ days), pruritic polymorphic rash, cervical lymphadenopathy, dry, red, cracked lips, strawberry tongue, bilateral conjunctivitis w/o exudation, erythema and swelling of palms and soles
75
kawasaki cm - subacute
10 -35 days
fever resolves and all cm disappear
vasculitis, desquamation of toes, feet, fingers, palms; arthritis, thrombocytosis (increased platelets - lots of echos, meds)
76
kawasaki cm - convalescent
up to 10 wks, until valves return to normal - very dangerous (thrombi and MI)
MI s/s (teach!!): abd pain, v, restless, inconsolable crying, pallor, shock
S free
77
kawasaki tm
salicylates for anti-inflam and antiplatelets: high dose ASA until afebrile for 48-72 hrs, start immediately upon admission, then low dose for antiplatelet (long term)
IVIG w/n 10 days of fever - decrease heart issues, fluid overload
78
kawasaki nc
monitor cardiac: o2 and resp, I+O (large volume of fluid with IVIG), vs q1-2 hrs until stable, daily weight, admin fluids with care (IVIG, blood), watch for S of MI - teach
IVIG: blood product precautions, large volume to child with myocarditis and diminished LV function, q15 min
relieve S: skin discomfort (cool cloth, unscented lotion, loose fitting clothing, chapstick), mouth care, clear liquids and soft foods, irritable - respite, quiet
discharge edu: accurate info on progression (follow up, aspirin therapy, irritability can persist, skin peeling is painless but dont peel, joint pain nc), immunization (no live for 11 mo, no varicella if on aspirin), MI possibility, asa - gi bleed, ringing in ears
79
hypospadias
urethral opening on ventral surface
increased risk of UTI, interfere with procreation, body image disturbance
80
hypospadias tm
sx (stages): void standing, improve phys appearance, functionality (procreate)
6-18 mo: anesthesia and before potty training
81
hypospadias nc
examine, delay circumcision (need foreskin), psych prep
82
hypospadias nc - post op
pressure dressing: check tip frequently, dont change
cath/stent care: closed drainage
double diaper (if open stent)
teach home care: no tub bath with external stent or cath (48 hrs), no sandbox, no straddle toys, dont carry on hip
83
UTI teaching
appropriate and careful specimen collection and handling, abx admin (bactrin, no amoxicillin), push fluids, promote comfort, adequate followup cultures, teach prevention
no bubble bath (tub good), no tight fitting clothes, empty bladder, schedules times, lots of fluid, pee after sex, change sanitary pads freq, cotton underwear, wipe front to back, finish abx, pain meds
return to clinic 7-10 days later - reflux if recurrent, check
VCUG after 1-2 in M and 2-3 in F
84
HUS
hemolytic anemia and thrombocytopenia with ARF
85
HUS cm
confused with gastroenteritis
v, marked pallor, oliguria or anuria, edema, fatigue, elevated BP, abd pain and tenderness, neuro change, irritable, altered LOC, seizure, posturing, coma
86
HUS lab findings
urinalysis: + for blood, protein, pus, casts
serum: elevated BUN and creatinine, anemia, thrombocytopenia, leukocytosis with left shift, hypoNa, hyperK, hyperP
87
HUS tm
maintain fluids, correct htn, acidosis, e abnormalities, replenish rbc, dialysis prn
no abx
88
HUS nc
contact! can shed for weeks, fluid volume status, fam support (dont know when or if child will get better, lots of complications), adequate nutrition w/n dietary restrictions (low salt and fluid restrict), monitor for bleeding (low plt), teach prevention (cook meat - temp no color, pasturized food, wash fruits and veggies, now well water, HH)
89
nephrotic syndrome (NS)
increased glomerular basement membrane permeability
90
NS cm
massive proteinuria, hypoproteinemia (in blood), hld, edema (generalized, no protein in blood)
in blood: protein low, cholesterol up
sudden rapid weight gain, pleural effusion, decreased UOP, d, anorexia, pallor, muehrcke lines, bp normal or low, freq infections, fatigue, hypoalbuminea, mild hematuria
peritonitis (measure abd girth)
91
NS diagnose
urinalysis
serology
renal biopsy
92
NS tm
reduce protein excretion (steroids 6-10 days oral)
reduce tissue fluid retention (albumin and lasix)
prevent infection, anemia, poor growth, peritonitis, thrombosis, renal fail
bed rest during edema, unrestricted during remission
no added salt, high P during edema, regular during remission
corticosteroids, immunosuppressant, loop diuretics, salt poor, albumin
93
NS nc
fluid volume excess - edema
IV fluid volume deficit - protein and fluid loss
infection - edema, decreased resistance, steroids
altered nutrition - decreased appetite and protein
ineffective breathing - ascites (edema)
body image disturbance - edema
activity intol
altered fam process
knowledge deficit
peritonitis (measure abd girth)
94
APSG
immune process damages glomeruli
strep
95
APSG cm
fever (active infection)
lethargy, fatigue, malaise, weakness; HA, anorexia/v, puffy face, discolored frothy coke urine with increased volume, edema and weight gain, flank or abd pain, htn and s/s of circulatory overload
p in urine but not as much as NS
HA!!! d/t htn, pain meds, monitor
96
APSG diagnosis
urinalysis: gross hematuria, mild proteinuria, elevated SG
urine culture: -
serology: normal e-, elevated ASO titer, BUN, and creatinine, and sed rate; rbc may be low
97
APSG tm
bed rest during acute (1-2 wk, usually self limited)
no added salt, low protein (if BUN elevated)
control htn (manual bp q4 hr, maybe prn meds)
abx if fever
isolate from other sick kids
better = increased UOP
98
APSG nc - fluid volume excess
daily weight, I+O, SG, monitor hematuria, BP, e- imbalance, s of cardiopulmonary congestion, safe diuretics, prevent infection
99
APSG nc - injury
d/t encephalopathy, renal fail, seizure - buildup of toxins they are not peeing out
assess s/s of renal fail, neuro eval, seizure precautions
100
APSG nc - knowledge deficit
teach how to take BP, follow diet, monitor urine output and color
101
ARF
sudden reversible decline in renal function
toxins accumulate, F+E imbalance
dehydration and nephrotoxic drugs - vancomyocin (peak and trough, stop med, give lots of fluids)
102
ARF tm
prevent, treat cause, manage F+E, decrease BP, supportive therapy
peak and trough
better = UOP restored
103
ARF nc
VS and I+O, regulate fluid intake, nutrition, monitor for complications, support and comfort
when urine output is restored, diuresis may be significant
104
VP shunt
manage hydrocephalus
high rates of malfunction - obstruction and infection
105
VP shunt nc - preop
prevent scalp breakdown, infection, damage to spinal cord (careful head handling)
monitor for increasing ICP
nutrition
keep eyes moist (may not close all the way)
prep
106
VP shunt nc - postop
bed rest with minimal handling immediately after sx (flat with no P on shunted side), later HOB 15-30
monitor vs, neuro, abd distention (fluid draining), s/s infection
comfort, discharge, record dev milestones
teach s/s of increasing ICP w/ d/c, no contact sports or army, dont pump shunt
107
VP shunt - infection
remove, external ventricular drain inserted and connected to bag
closely monitor EVD, IV abx for weeks, new shunt once CSF clear of infection
108
VP shunt - malfunction
new shunt insertion
cause: growth, disconnected tubing, kinks
109
hydrocephalus
excess csf in ventricular system
same s/s as increased ICP
110
increased ICP cm - children
HA, blurred vision, diplopia, pupils sluggish to light, seizure, n, forceful v, lethargy, increased sleeping, declining school performance, declining motor function (change in gait)
111
increased ICP cm - infants
tense bulging fontanelles
separated cranial suture
macewen (cracked pot) sign
irritable
high pitch cry, catlike
increased head circumference
distended scalp veins
feeding change
cry when held or rocked
setting sun eyes
taught shiny skin over scalp
112
late S of ICP
significant decrease in LOC
decreased motor response to command
decreased sensory response to pain
fixed and dilated pupils
decerebrate/decorticate posturing
cushings triad: SBP up, RR + HR down, PP widen
113
hydrocephalus tm
relieve P, mechanical shunting of fluid
treat cause and complications
promote psychomotor dev
114
TBI - basilar skull fracture
break in base of skull, close to brainstem = serious
higher risk of secondary infection (meningitis, no invasive - no suction, high alert for fever, nothing up the nose, s/s of meningitis or other infection)
raccoon eyes and battle sign, CSF leakage possible (nose and ears)
115
TBI - tm
ABCs, stabilized neck and spine, freq neuro and vs, hypertonic solution (mannitol, hypertonic saline = draw fluid into vasculature and away from brain), IV steroids to decrease inflam and edema
116
TBI S of progression
mental status change, mounting agitation, dev of focal lateral neuro s (posturing, one eye changes), marked change in VS, cushing reflex, S of brainstem involvement
117
concussion - when to seek treatment
infant, lost consciousness, wont stop crying, head and neck pain, repeated v, difficult to awaken, difficult to console, change in gait, unusual behavior, bleeding from nose/mouth, watery glucose discharge from nose or ears
118
concussion cm
confusion and amnesia!!
HA, dizzy, difficulty concentrating, vision change, sensitive to light and noise, n, drowsy, tinnitus, irritable, loss of consciousness, hyperexcitability
119
EVDs
dont mess with drains
bad waveform or lots of drainage = call surgeon
120
EVDs nc
dont turn side to side (increase ICP)
keep HOB 15-30
drainage level with tragus (or surgeons order)
assess CSF output every hour
dont change dressing
sudden increase or decrease in CSF output or poor waveform = all stopcocks in correct direction, cords plugged in, thorough and quick assess, call surgeon
121
nc - unconscious child
emergent
ASSESS - subtle cues
ABCs, stabilized spine, treat shock, reduce ICP
122
nc - unconscious child
ongoing
freq neuro assessment
LOC, pupillary reaction, VS
pain management - tylenol or ibuprofen, no morphine or opioids (sedation)
123
nc - unconscious child
pain signs
increased HR and BP = pain
resp, ICP, nutrition and hydration (unconscious 3+ days), elimination (usually foley), thermoregulation (blanket), positioning (turn), hygiene, meds, stimulation - talk to them but no parties (low stim, dim light, bumb bed), fam support - dont know how they will be when they wake up
124
meningitis
inflam of meninges in brain and spinal cord
less with abx and vaccines
bacterial = bad, permanent damage
viral = vanishing, not as bad
125
meningitis cm
poor suck and feed, apnea, weak cry, nvd, tense fontanelle, jaundice, fever, increased irritability, high pitch cry, seizures, HA, petechial or purpural racsh, altered sensorium, opisthotonos, kernig's sign, nuchal rigidity (brudzinski's)
126
meningitis tm
diagnose: LP = increased WBC (cloudy), P, protein; decreased glucose, + culture
meds: abx if bacterial or until cultures return, anticonvulsants, antipyretics
treat F+E imbalance
127
meningitis nc
isolation first! collect specimens (1 hour), then abx ASAP
prevent complications, seizure precautions and neuro checks, prevent increase in ICP, hydration and nutrition, support (dont know if they will get better or what they will look like)
monitor for septic shock, circulatory collapse, dilutional hypoNa, long term sequelae
prevention
128
febrile seizure
>101, 6 mo - 5 yrs, w/o epilepsy, CNS infection, or met abn
129
febrile seizure tm
>5min = call EMS
meds = rescue sedative (rectal diazepam or intranasal midazolam)
130
epilepsy tm
1. antiepileptic drugs (start with 1, may need multiple)
2. keto diet (high fat, low carb, supplement with vits)
3. vagus nerve stimulator -device under skin, use magnet?
4. surgery
131
keto diet
high fat low carb
no fries, buns, pasta
full fat: ice cream, milk, etc
132
epilepsy nc - during seizure
1. observe (eye movement, LOC, uni/bilateral movement, duration)
2. protect - lower bed, protect head, turn on side, NPO, dont restrain
3. VS, oxygen if <90%
4. >5 min = rescue sedatives
5. call hcp and monitor
133
epilespy nc - long term
educate caregivers (rescue meds - always have and admin)
avoid triggers (sress, sleep deprivation, flickering lights)
safety (dont bathe/swim alone, helmet, no open flames, avoid climbing tall heights)
support - balance autonomy and safety, med alert bracelet
134
down syndrome nc
support fam, assist in preventing physical problems, promote dev progress, assist with genetic counseling
135
down syndrome cm - physical
inner epicanthal folds, depressed nasal bridge, small nose (stuffy, hard time expectorating, high risk of resp infection, humidifier, blow nose, suction), excess/lose skin on back of neck, atlantoaxial instability, high arched palate, large protruding tongue (feeding difficulties, be persistant), simian crease, decreased muscle tone (excess neck support, swaddle, thermoregulation, constipated), wide space between big and 2nd toe (wider stance so fall risk)
136
down syndrome cm - cognitive
lower intelligence, social dev delay, cognitive anomalies, sensory problems, height and weight reduced bu weight is high for height (obese), sex dev often delayed
137
down syndrome complications
feeding difficulties, obesity, constipation, congenital heart defects, acute otitis media, leukemia, hypothyroidism, upper resp infections
138
adhd tm
referral to learning specialist may be helpful
1st line (4-5 yr): behavior and psychotherapy
pharm therapy: psychostimulants - methylphenidate, others - tricyclic antidepressants
139
adhd associated issues
school or academic difficulties, social difficulties
risk of: conduct disorders, oppositional defiant disorders, depression and anx, dev disorders like speech and lang delays, learning disabilities
140
ADHD - med considerations
stimulant SE: weight loss, abd pain, decreased appetite, sleeplessness, HA, growth velocity
usually at bfast and noon, immediate release on empty stomach, avoid caffeine, insulin may nee adjust, no drug holidays, freq eval effectiveness
see every 6 mo to monitor SE
141
adhd
dev inappropriate degrees of inattention, impulsiveness, hyperactivity
diagnose based on activity in 2 different settings and behavior before age 7 (starts around 4, normal dev behavior before that)
142
muscular dystrophy
mutation in gene for protein in muscles leading to degeneration
143
MD early cm
btw 3-5 years of age: running, bike, stairs
rapid progressive muscular degen after initial normal dev
waddling gait, lordosis, + growers sign (walk up legs to stand)
brain intact
144
MD progressive cm
pesudohypertrophy: muscles look like they get bigger but just fat deposits
ambulate ability lost 10-12 yr
facial and resp atrophy
cardiac or resp failure
mild - mod cognitive impairment
27 yrs with mechanical vent
145
MD complications
contractures - hips, knees, ankles, spines
atrophy from disuse
infections - resp
obesity - inactivity
cardiac - end stages
146
MD tm
maintain function in unaffected muscles: rom, brace, adls, sx, walker before wheel chair
genetic counseling - parents
147
MD nc
treat complications - contractures and atrophy: pt/ot, orthotics
nutrition - slp
resp failure - cough assist, mech vent/trach, vaccines
cardiac failure - diuretics and digoxin
slow progression - corticosteroids, CT GalNAc transferase, glutamine and creatine monohydrate
palliative: coping, program to increase independence, reduce preventable disabilities, modify home
148
spina bifida
malformation of spine - posterior portion fails to close, failure of neural plate to develop into tubular structure
from low folic acid (vit B)
can be detected prenatally - prenatal sx can happen, or c section
149
spina bifida occulta
only vertebrae, may not know you have it, no neuro deficits
150
spina bifida meningocele
missing vertebrae and protruding sac (w/o nerves), no neuro deficits
enclose area, put sac back in
151
spina bifida myelomeningocele
nerves in sac - neuro deficit
damage depends on where your sac is - most incont and paralyzed from waist down
152
myelomeningocele tm
sx to close sac w/n 24 -72 hrs, 12 - 18 hrs if possible to prevent infection and preserve roots
neuro and plastic sx
153
myelomeningocele cm
sac like protrusion evident at birth
hydrocephalus (s/s = enlarged head, bulging fontanelles, sunset eyes, downward displacement of brain stem/ cerebellum causing obstruction of CSF)
varying degree of sensory and neuro dysfunction
poor muscle tone in bladder and rectum, flexion or extension contracture
154
myelomeningocele nc - preop
prevent infection: moist, sterile, NS, nonadherent, no diaper; keep genitalia clean, cath
protect sac: prone, early closure
no rectal temps - rectal prolapse or lack of bowel control
155
myelomeningocele nc
vs, weight, I+O, pain, prone, observe incision
feed when awake - have parents hold
orthopedic - improve locomotion and prevent deformities post op (ROM, position changes)
urinary incontinence: clean intermittent cath (can learn by 6, urinary diversion)
measure head circumgerence and contanelle
assess s/s of infection
latex free (early sx)
nutrition and hydration
promote normal dev: gh for growth hormone
156
myelomeningocele bowel incont
bowel training, prevent c - laxatives, digital stim, enemas
diet mod
antegrade continence enema procedure
157
cerebral palsy
permanent disorders of dev of movement and posture leading to activity limitation that are because of a nonprogressive disturbance in the fetal/infant brain
problem of brain, not muscle
158
spastic cerebral palsy
contractures, drool, more severe
scissoring (knees cross)
159
cerebral palsy diagnosis and cm
missed mile stones and persistent reflexes (moro, tonic neck, grasp past 6 mo), abn muscle tone (hypertonic/hypotonic), c shaped back, not sitting up at 8 mo - PT, holding up head, rolling over, sitting, crawling, smiling, floppy or limp posture, stiff or rigid arms or legs, use one side of body or only arms to crawl, hand pref before 18 mo, uncoordinated or involuntary movements, facial grimacing, writhing movements, poor suck, ataxia
no smile by 2 mo, feeding difficulties (gag, choke, tongue thrust after 6 mo), extreme irritable or cry
often to present until 6-12 mo (most milestones here)
160
DDH - pavlik harness
0-6 mo
pavlik harness - no thick diapers, check skin breakdown, always on except bath, creative holding (football hold), clothes under, no lotion or powder, massage under
161
osteogenesis imperfecta cm
brittle bone disease (precollegen issue)
often confused with abuse
bone fragility and deformity, poor growth, bruising and recurrent epistaxis, blue sclerae, hearing loss, thin skin, diaphoresis and teeth discolor, mild hyperpyrexia, normal intelligence
decrease fractures in adolescence
162
osteogenesis imperfecta tm
support: prevent break, muscle weak, osteoporosis, malalignment
brace, swim, traction, moderate activities, rods with bone, activity non contact, pt, splint, pamidronate med - bone healing and decreased bone reabsorption
163
osteogenesis imperfecta nc
handle carefully (bp and moving in bed, etc), teach limitations to increase g+d, family support
no contact sports, swim
164
cast purpose
immobilize affected part, usually fiberglass (palms only, no fingertips - pressure points), no fan or hairdryer to accelerate drying
165
cast pain
meds (range), no ibuprofen bc interferes with recovery
ice - itch, swell, pain
elevate
skin breakdown, 5 Ps (few fingers)
166
cast mobility
exercise non affected side, isometric on affected side
prevent foot drop, keep moving and active
167
casts healing
diet and fluids
168
casts - neurovascular
5 Ps (pain, paralysis, paresthesia, pulse, pallor)
elevate, tightness (few fingers)
169
casts - complications
keep heel off mattress, feel hot spots and tingling, wound drainage, skin break down (petal edges with moleskin)
170
casts - removal
scary - distract, headphones
explain and demonstrate on self, put vibrate on them to feel, cant cut skin
maybe restrain
171
CF tm
prevent infection! nutrition!
rep: aggressive airway clearance (percussion, therapy, postural drainage, breathing exercises, physical exercise), oxygen therapy, aerosols, nebs
drugs: abx (prophylactic), ccl activators, Na blockers, mucolytics, bronchodilators
GI: pancreatic enzymes (before snacks/meals, sprinkles), fat soluble vits, stool softeners, NaCl tablets (hot), oral iron, monitor BS
other: anti inflam and proteaseI, immunizations, lung transplant (not a cure)
171
juvenile arthritis - tm
NSAIDs - atc (adjust with growth)
DMARDs - methrotrexate
biologic agents - humira or enbrel
corticosteroids
others: decrease inflam, and ROM
heat and exercise, prevent deformity (PT/Ot, ROM), relieve s (pain), swim, play
goal: inflam, then ROM, heat and excercise (am, swim, wiggle, prone to watch tv)
172
cf etiology
normal function of Na and Cl transport disrupted - impaired fluid secretion and abnormally thick secretions
172
CF nc
resp assessment, vigilant pt and treatments
assess IV site and judicious abx admin
enzyme replacement
exercise and fun
isolation - mask outside room, no comingle
high cal foods, shakes, nutrition eval, dont limit fat
fam impact
hospital v home care
173
cf - resp effects
chronic pna, obstructive emphysema
s/s: wheezy cough, increasing dyspnea, thick rattling extremely productive cough, cyanosis, pneumonia, polyps in nose, clubbed digits, chronic sinusitis
174
cf - gi effects
intestinal obstructions
degen of pancreas - malabs - dm
s/s: appetite change, steatorrhea, azotorrhea, weight loss, tissue wasting, distended abd, sallow skin, anemia
175
asthma - med delivery
metered dose inhaler + spacer
good seal - face mask
one pump at a time, about 10 breaths, 1 min between puffs
176
cf - other effects
hepatic - bile ducts
s/s: ascites, gi bleed, jaundice
reproductive: delayed puberty
e loss, salty sweat, dehyd, hypoNa, heat stroke
177
asthma - red zone
emergency = rescue meds
short acting beta 2 adrenergic agonists
bronchodilators (albuterol)
177
asthma - green zone
well controlled asthma
continue preventer meds (corticosteroids, beta 2 adrenergic agonists)
178
croup - viral
LTB
slowly progressive, inflam of mucosal lining causing narrowing of airway
178
asthma - yellow zone
add or increase preventer meds
bronchodilator, sit out of PE for a while
179
RSV - tm
always suction first!
180
LTB cm
sound worse than they look
airway restriction
sudden onset of harsh, metallic, barky cough, insp stridor or hoarsness
resp distress
retractions
agitation
pallor or cyanosis
increased HR, extreme restlessness, listlessness
hypoxia
181
LTB tm
usually at home
priority: airway, breathing
calm!, humidity with cool mist (outside night, shower, mist tent, etc), humidified O2, adequate fluid, comfort, racemic epi (rebound), corticosteroids
no bronchodilators or abx!!! avoid cough syrups and cold meds
181
LTB nc
resp status
conserve E
decrease anx (P at bedside)
assess for and prevent dehyd
support fam
182
epiglottitis
bacterial croup
serious, life threatening obstructive inflam process
182
epiglottitis cm
look bad, dont sound bad
abrupt onset, start with sore throat
high fever, mouth open, tongue protruding, drool, agitation
looks very sick, sit up - tripod
sore red inflamed throat, difficulty swallowing
muffled voice, insp stridor, no cough
183
epiglottitis tm
no tongue blades, avoid xray and transport, let parents be with child, prep for intubation and sedation (then specimens)
antipyretics for fever
IV abx until extubated (dramatic improvement after 48 hr, 7-10 days)
d/c with oral abx at home
184
pertussis
whooping cough
vaccine - tdap
infants: <6 mo = apnea; >6 mo = paroxysmal cough
older = persistent cough
185
pertussis - tm
erythromycin and azithromycin
<6 mo = vent
humidified O2
hydrate
watch and prevent pna
186
tonsillectomy nc
observe s/s of excessive bleeding - swallowing
position on side for drainage
avoid suction - drool ok
no straw, cough, laugh, cry, strain
diet - soft diet, no red, no milk
inspect secretions and v - blood tinged is ok, not copious amounts
watch for stridor - airway compromise, stethoscope on throat
comfort ice collar
pain management - atc
cool mist vapor
186
otitis media - prevent
vaccines on time, no smoking, avoid daycare if possible, breastfeed for 1 year, allergies - running nose; dont prop bottles - upright for feeding
get water out: 1/2 peroxide, 1/2 vinegar; ear plugs, hair dryer on cool setting, gravity + wiggle
187
otitis media rf
males, younger, non breast fed, lay down alot, exposure to cig smoke and many people, bottles in bed, unimmunized, pacifier use beyond infancy, fam hx, allergic rhinitis, acquired immune deficiencies, craniofacial anomalies, winter
188
gastroschisis nc - preop
more severe, born c section
herniation of abd contents, no sac
loosely cover with saline soaked nonadherent pads and plastic drape, warmer
IV fluids, abx, sx correction (stages, silo)
sterile technique, careful handling, monitor for ileus (listen to BS through silo), fam support, d/c planning, home care
188
GERD - reduce
elevate HOB 30 (wedge under mattress, harness)
small freq w/ thickened (rice cereal)
avoid fatty foods - chocolate, tomato, carbonated liquids
burp freq
educate: hold upright - no stroller or car seat
188
clef lip/palate nc - post op
protect airway: position on belly for palate, may be on side for lip
hypothermia
prevent infection - ointment
protect suture line: not prone after lip, nonos
pain manage - atc
avoid objects in mouth, suction with caution, or sharp objects in mouth
bonding
long term: speech, dentition, hearing
discharge: oral care (orthodontic), ear infection and hearing, speech development
189
cleft lip/palate feeding preop
breast feed usually not possible
upright, special nipples, pigeon feeder, stimulate suck reflex, swallow appropriately (watch for asp), rest (30 min), burp freq
elongated nipple (haberman), squeeze into mouth a little at a time
190
mild dehydration
weight loss 3-5%
active alert
moist mucous
tears present
treat: ORS
191
mod dehydration
weight loss 6-9%
irritable, alert, thirsty
cap refill >3sec
slightly increased pulse
slight tachypnic
normal or low ortho hypot
dry mucous membranes
less tears
brief tenting
normal or sunken fontanelle
reduced urine flow
treat: ORS
192
severe dehydration
weight loss >10%
lethargic, look sick
cap refill >4 sec
fast and thready HR
fast and deep breathing
orthostatic to shock hypot
parched mucous membranes
absent tears
sunken eyes
prolonged tenting, mottling, acrocyanosis, cool skin
significantly sunken fontanelle
severely reduced urine flow
treat: IV fluids
193
holliday segar
>10 kg = 100
>20 = 50
20+ = 20
194
constipation tm
quality not quantity
diet: increase fiber (5+age), increase fluids 1st (water, fruit juice)
educate: activity, stool softeners (miralax - 6 mo)
fiber: fruits and veggies (not choking hazard), beans, green leafy, whole grain
regular potty times, daily, 30 min after dinner
right size - feet on floor, not falling in, relax anal sphincter
encourage to not hold it
treat for 6 mo
195
HIV tm
antiretroviral until 1 mo, mom on retroviral 2nd and 3rd trimester (not first - organs), aggressive abx with infections, modified immunization schedule (based on wbc numbers), prophylaxis
196
HIV nc
prevent, infection risk (neutropenic), knowledge deficit (teach transmission, med storage), altered nutrition (increased protein and cal, preferred foods, supplements, altered g+d, caregiver anx, pain
197
neutropenic precautions
anc < 1000
VS (temp >100 = emergency), HH, inspect skin and mouth, no flower or plants, decrease bacteria in food (right temp, no skins, no pepper), changes dressings and lines with sterile technique, no live vaccines, avoid contact with ill, wear mask outside room
198
anemia - oral Fe
acidic env (orange juice), with straw, rinse after, measure accurately, increase fluids and fiber, avoid antacid, coffee, tea, dairy, egg, whole grain 1 hr before and 2hrs after
SE: n, gastric irritation, cd, anorexic, constipation, teeth stain, tarry stool, OD lethal - lock up flinstones vits
199
sickle cell crisis cm
swelling! s/s of anemia
200
anemia cm
anorexia, pallor, skin breakdown, jaundice, tachy x2, altered neuro or behavior change, weak or low exercise tolerance, gum hypertrophy, smooth tongue, blood in urine or stool, infection, cold intolerance
201
sickle cell crisis management
hydration - will decrease pain
oxygenation - rest and remove restrictive clothes
atc pain management - chronic, morphine, tolerance
support - temp, fearful, anx, chronic
202
chemo SE
kills normal and cancerous
short term: immunosuppression, infection, myelosuppression, n/v, oral mucositis, alopecia
long term: microdontia and missing teeth, hearing and vision changes, hematopoietic, immunologic or gonadal dysfunction, various alterations of systems, 2nd cancer
203
chemo - bone marrow suppression
admin blood safely, nc for anemia, nc for thrombocytopenia, colony stimulating factors, nc for neutropenia
204
chemo - alopecia
most adjust well, hat, scarves, wigs, will grow back (different color/texture)
205
chemo - stomatitis
multiple ulcers
prevent: oral mucosa and teeth clean, antifungal and bacterial mouthwash, avoid acidic
treat: rinse with NS, magic mouth wash, avoid local anesthetics - lidocaine (cant swallow)
205
chemo - n/v
antiemetics before chemo and q3-4 hours until drugs clear, avoid strong smells, small and freq, cool, chemo early in day
206
chemo - fear and anxiet
inform, plan of care with family, assess coping, optomistic, no false hope, resources, diversional activities
206
oncologic emergencies
hemorrhagic cystitis
tumor lysis syndrom
septic shock (monitor for circulatory failure)
hyperCa from large bone destruction (hydrate and P supplement)
207
hemorrhagic cystitis
bladder pain and blood in urine
increase fluid intake, void frequently, mesna to protect bladder
208
tumor lysis syndrome - cm
flank pain, lethargy, n/v, oliguria, pruritus, arrythmias, impaired renal, tetany, neuro change
209
tumor lysis syndrome
tumors release high uric acid, k, P into blood leading to metabolic acidosis, renal failure, death
rf: large tumor/lots, sensitive to chemo, increased proliferation rate, high wbc at diagnosis
210
tumor lysis syndrome - tm and nc
med = alpurinol
fluid before therapy (3-4x maintenance), i+o, daily weight, urine specific gravity <1.01, e and meds to decrease conversion of metabolic by products to uric acid, urine pH (7-7.5), monitor for tetany and mental change, collect labs
211
PKU diet
formula - for life
no protein (milk, dairy, meat, fish, chicken, eggs, beans, nuts)
limit cereal, starch, fruits and veggies, grains
212
hypothyroid - med admin
avoid heat exposure, dont mix with soy (apple sauce ok), adjust with growth,
213
growth hormone - educate
set realistic expectations
daily SQ, at night, until adult height reached, very expensive, 5-7 times per week, ice, school aged
dress and act and treated as the age they are
214
hypogly s/s
<60
low bg, hunger, HA, confusion, shaky, dizzy, sweat
check BS
215
hypogly tm
check, 15 g rule (1/2c juice or soft drink, 1/2c milk, glucose tab, cake icing, starburst, dissolvable, gummies, honey > 1 yr, NO CHOCOLATE of fat), follow with meal/snack (protein)
severe - no swallow: glucagon emergency (expires), IM/SQ, on side bc v, feed when awake
216
dka cm
deep and rapid breathing (kussmal, resp distress w/o lung patho), v dry mouth (dehyd with excessive UOP), , fruity breath, n/v (w/o d), lethargy, drowsy
cerebral edema, hypergly, hypovolemia
insulin deficiency with countereg to enhance gluconeogenesis, glycogenolysis, lipolysis
hyper/hypoK: K loss from shift to extra to exchange with excess H+ in extra, out in urine
dehyd: increased serum osmolarity, h2o shift extra, dilutional hypoNa - out in urine
217
dka tm
correct dehyd, acidosis and reverse ketosis, restore normal BG, avoid complications
218
dka tm - fluid
NS at 10-20 mL/kg/hr, replace fluid deficit evenly over 48 hr
confirm DKA with labs
219
dka tm - insulin
separate IV, prime with insulin, not given in first hour bc r/o cerebral edema, d/c any bodily insulin pump
0.1 U/kg/hr, continue until acidosis clears
this will turn off ketone production, decrease blood sugar, check glucose q1hr
low dose to decrease hypogly or hypok, dont drop more than 50-100 mg/dL/hr (cerebral edema)
dont d/c based only on BG - pH >7.3 and HCO3 > 15 and serum ketones clear
before admin: neuro, VS, BG
continuous IV infusion, regular, high alert, dont give as bolus
once BG 250 - 300, maintain insulin and give dextrose (acidosis takes longer to fix)
220
dka tm - K
hour 2 if urinated
start with insulin, consult pharm
monitor! usually significant K deficit
continue throughout IV therapy
max rate is institution specific
221
dka tm - dextrose
maintain BG 150 - 250, prevent hypogly
add to IV when BG 250 - 300, change to 5% with .45 NaCl at rate to complete rehydration in 48 hr, check BG q1hr, electrolytes q2-4hr
SQ insulin after DKA resolves
222
DKA tm - transition off IV insulin
pH > 7.3 and HCO3 > 15 -18, AG < 12, eat
SQ, d/c IV, IV dextrose, feed
known DM pt: prior dosing
new DM pt: .7-1 U/kg/day
223
general resp nursing interventions
ease respiratory efforts, promote rest, comfort, prevent spread of infection, promote hydration and nutrition, manage fever, fam support and teaching, support and plan for home care
224
nc to ease resp efforts
position, warm or cool mist, mist tent, saline nose drops with bulb suctioning, bed rest, quiet activites
225
nc to prevent spread of infection
HH, teach, judicious room assingments, immunizations, abx
226
nc to improve oxygenation
cough and deep breathe, suction, neb meds, percussion and postural drainage, cpt, supplemental o2
227
nc for hydration and nutrition
high cal fluids, avoid caffeine, allow to self regulate
228
tonsillectomy dc teaching
days 7-11
excessive swallowing, excessive bleeding, clearing their throat
comfort and pain measured
229
cardiac defects cm
dyspnea, ftt, feeding difficult, stridor or choking, HR>200, rr>60, recurrent RTI, poor dev, delayed milestones, decreased exercise tolerance, cyanosis and clubbing, squatting, heart murmu, excessive perspiration, s of HF
230
dm 1 - tm
extra snack before exercise
glargine and lispro
eat whatever, adjust with insulin (carb count)
231
check ketones
sick, >240 x2 or 1 on pump
232
anemia - nc
prep for lab test, decrease O2 demands, safety, HH and oral care, body temp, prevent complications, support fam
233
cancer - CNS involvement
HA, persistant n/v, irritable, dizzy, seizure, behavior change, 6th cranial nerve palsy (eye tract)
234
anemia cm
anorexia, pallor, skin breakdown, jaundice, tachy x2, altered neuro or behavior change, weak or low exercise tolerance, gum hypertrophy, smooth tongue, blood in urine or stool, infection, cold intolerance
235
platelets: >100,000 - normal
no contact sports, protective equip
236
platelets: 50 - 100,000
padding, protective
237
platelets: <50,000
quiet activities, extreme caution
238
platelets: >20,000
return to school
239
anemia tm
treat cause (transfusion, nutrition)
supportive: IV fluids, O2, bed rest
240
decerebrate
arms extended, wrists flexed back, arched back
241
decorticate
elbows bent and brought to chest
242
rooting
birth - 3/4
head midline, stroke cheek, open mouth and turn head to stimulated side
243
asym tonic neck
birth - 4/6
supine, rotate head, hold 15 sec, arm and leg extend on facial side, arm and leg flex on other side
244
palmer grasp
birth - 3/6
place finger in palm, grasp
245
stepping
birth - 6/8 wk
held as though weight bearing, steps along 1 foot at a time
246
moro (startle)
birth - 4 mo
loud noise or drop head, arms spread and fingers extend, then flex, then arms come toward each other, cry possible
247
babinski
birth - 2 yr
stroke bottom of foot heal to toe, great toe flexes and others fan
248
landau
3 mo - 15m/2yr
suspend prone while supporting abdomen, head and legs should lift
249
parachute
6/8mo - never
suspend prone and lower towards table, arms, hands and fingers should extend
250
pain
251
hospitalized infant
see around them, talk to them, touch/swaddle/talk softly, bring to nurses station, smile and put face in field of vision, home routine, group care, same nurse, keep frightening objects out of view, attention to over stim, hold when feedings (even NG)
252
hospitalized toddler
routine, security object, praise, mobility and aggression outlets, finger food, exploration, guided choices, repeat syllables
253
hospitalized preschooler
specific language, be aware of distractions, silly mistakes and let them catch you, socially acceptable words, comfort, transitional object, lets do this, how about, please and thank you, throw and catch, routines, read!
254
hospitalized schoolager
school work, truthful explanations, quiet and private time, teach new staff, make things, collect, games
255
hospitalized adolescent
teach at their level, involve with new staff, talk about future, ask about parent involvement, high expectations for appropriate behavior, help maintain identity, normal assessment findings, stay connected with friends
