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Post-operative nursing care for a child with Hirschsprung Diseasse

-assessing for return of peristalsis, providing hydration and nutrition, IV fluids, wound care, psychological support

• Pain management
• Support nutrition and establish feedings
• Care of stoma and skin
• Family education (Parents must know stoma care)


What is precocious puberty?

Development of secondary sexual characteristics before age 8 in girls and age 9 in boys. Precocious puberty is a normal variant in 80-90% of girls and 50% of boys.


What are some causes of precocious puberty?

• Pituitary stimulating tumor
• Ovarian tumors or cysts
• Exogenous sources of estrogen in females
• Adrenal hyperplasia or adrenal tumors in males


Medical and nursing management of precocious puberty:

Monthly injections of lutienizing hormone releasing hormone to regulate pituitary secretions

Child and family support
• Early puberty related to increased anxiety and decreased self esteem in children
• Important to remember these children are likely to be fertile
• Emotional and cognitive abilities correlate with chronologic age


What is Hirschsprung Disease?

Absence of parasympathetic ganglion in portion of bowel results in loss of peristalsis in affected segments, accumulation of stool and bowel obstruction. Usually diagnosed in infancy but mild cases may not be diagnosed until later in childhood.


Signs and symptoms of Hirschsprung Disease?

• Neonate: delayed passage of meconium, poor feeding, bilious emesis and abdominal distension
• Infant: infrequent stools failure to thrive, distended abdomen, diarrhea and vomiting
• Child: encopresis, constipation, foul smelling stools, difficulty toilet training, visible peristalsis and palpable fecal masses


Management of Hirschsprung disease?

• Diagnosis made through identification of aganglionic sections of colon with rectal biopsy.
• Treatment consists of temporary colostomy with later endo-rectal pull through surgery


Pre-operative nursing care for a child with Hirschsprung Diseasse

• Support fluid, electrolyte, and nutrition balance (NPO prior to surgery and older children may be malnourished
• Promote bowel evacuation (NG suction and may require bowel prep to remove old stool)
• Alleviate anxiety and support bonding


Primary causes of Diabetes Insipidus are
__________ or __________ and secondary causes can be __________, ________, & ___________.

familial or idiopathic

Tumors, infections and Vascular anomalies


The principal disorder of posterior pituitary hypofunction is _____________ which is an under secretion of antidiuretic hormone (ADH), or vasopressin (Pitressin), and producing a state of uncontrolled diuresis

diabetes insipidus


Cardinal signs of Diabetes insipidus are _________ & ____________. In older children, signs such as excessive urination accompanied by a compensatory insatiable thirst may be so intense that the child does little more than go to the toilet and drink fluids.


Polydipsia (thirsty)


Simplest test used to diagnose Diabetes Insipidus

restriction of oral fluids and observation of consequent changes in urine volume and concentration.



Why is AQUEOUS VASOPRESSIN given to a child suspected to have Diabetes Insipidus?

- The administration of injected aqueous vasopressin should alleviate the polyuria and polydipsia. ******Unresponsiveness to exogenous vasopressin usually indicates nephrogenic DI.


Therapeutic Management Treatment for Diabetes Insipidus?

- requires hormone replacement using vasopressin.

- Vasopressin is administered by intramuscular or subcutaneous injection or using a nasal spray of aqueous lysine vasopressin

-The injectable form has the advantage of lasting 48 to 72 hours; however, it has the disadvantage of requiring frequent injections and proper preparation of the drug.

**** Medical alert bracelet


Clinical Manifestations of Type 1 Diabetes Mellitus

-Weight loss
-Enuresis or nocturia Irritability; “not himself” or “not herself”
-Shortened attention span
- Lowered frustration tolerance
- Dry skin Blurred vision -
- Poor wound healing -
- Fatigue
- Flushed skin Headache -
- Frequent infections -


Ketoacidosis Treatment

- Administration of Bicarb - reduce acidosis and protect heart muscle
- Kusmal breaths to breathe off C02
- Hydration - (dehydrated b/c they are over saturated with sugar)
- Insulin (after hydration)


Diagnostic Evaluation for Diabetes

- Fasting glucose, if elevated repeat one week later.


Causes of hypoglycemia is diabetic kids

- Increased activity
- Decreased nutrition
- GI sickness
- Infection


What test results are diagnostic of Diabetes

(1) 8-hour fasting blood glucose level of 126 mg/ dl or more,

(2) a random blood glucose value of 200 mg/ dl or more accompanied by classic signs of diabetes,

(3) an oral glucose tolerance test (OGTT) finding of 200 mg/ dl or more in the 2-hour sample,

(4) hemoglobin A1C of 6.5% or more is almost certain to indicate diabetes


Risk factors that can lead to dehydration:

-Increased total body water
Water accounts for ~ 70% of body weight in the full term infant.
Water accounts for ~ 52% of body weight in the young adult female.
Fat is essentially water free so as child matures and body fat increases, percentage of total body water decreases.
Infants also have a higher percentage of extracellur fluid compared to intracellular fluid.
Extracellular fluid is utilized and replaced much more quickly than intracellular fluid.

-Increased body surface area
The large body surface area of the infant and young child increase the amount of insensible water loss.

-Higher metabolic rate
Increased metabolic rate requires increased amounts of fluid to support metabolic processes.

-Immature kidney function
The GFR in the term infant is ~1/3 that of an adult
The term infant has decreased ability to concentrate urine and excretes large volumes of dilute urine.
The infant kidney is also less able to excrete hydrogen ions to compensate for metabolic acidosis

-Immature speech, cognition, and motor skills
The very young child may be unable to verbalize thirst or to take action to relieve thirst.


What are the three types of dehydration

- Isotonic
- Hypotonic:
- Hypertonic:


Treatment for Hypotonic dehydration

IV with sodium rich fluid


Hypertonic Dehydration

- Results from water loss in excess of electrolyte loss and is usually caused by a proportionately larger loss of water or a larger intake of electrolytes.

- In hypertonic dehydration, fluid shifts from the lesser concentration of the ICF to the ECF.

-Plasma sodium concentration is greater than 150 mEq/ L.


_______dehydration is the Most dangerous type of dehydration



Isotonic (isonatremic)

- most common inadequate intake

- primary form of dehydration occurring in children.

- occurs in conditions in which electrolyte and water deficits are present in approximately balanced proportions.

- Shock is the greatest threat to life in isotonic dehydration, and the child with isotonic dehydration displays symptoms characteristic of hypovolemic shock.

- Plasma sodium remains within normal limits, between 130 and 150 mEq/ L.


treatment of dehydration

1. Restoration and maintenance of intravascular volume and systemic perfusion
-Initial therapy focuses of treating or preventing shock
-Mild dehyration may be treated with oral fluid replacement
-For moderate to severe shock must have vascular access

2. Replacement of fluid and electrolytes
-Fluid replacement with isotonic fluids
=NS or LR usually first choice
=May require colloids if intravascular dehydration not responsive to fluid bolus

3. Provision of maintenance fluid

4. Supportive care
-Monitor respirations
=May be inadequate if child is tachypneic or acidotic
-Monitor electrolytes, glucose, urine output
- Weight
-Vital signs
- If the child's condition is deteriorating early vital sign changes will be heart rate and respirations.
-Blood pressure is usually the last vital sign to change as child's condition worsens.
-Also assess: color, perfusion, activity, responsiveness, feeding behavior


nursing care management for a child with congenital adrenal hyperplasia

-of major importance is recognition of ambiguous genitalia and diagnostic confirmation in newborns

-cortisol and aldosterone replacement are the treatments

-during stressful situations cortisol disagree must be tripled to accommodate the body's increased need for glucocorticoids. failure to meet this requirement will precipitate an acute crisis. overdose appears as cushingoid signs

-sudden termination sof ht drug because of inadequate supplies, places the child in danger of an acute adrenal crisis. teach parents to always have a spare supply of medication.

-undesirable side effects of cortisone include gastric irrigation, increased excitably and sleeplessness, weight gain, occasionally behavioral changes.

-infants are especially prone to dehydration and salt-losing crises, parent need to be aware of signs of dehydration.


fluid maintenance calculation

100 ml for each of the first 10kg = up to 1000 ml
50ml for each kg 11-20 = up to 500 ml
20 ml for each additional kg



ph: 7.35 - 7.45
pCO2: 35 - 45mmHg
HCO3: 22 - 26 mEq/L


palliative care:

-palliative care for children is the active total care of the child's body, mind, and spirit and involves giving support to the family.

-it begins when illness is diagnosed and continues regardless of whether or not a child receives treatment directed at the disease.

-health providers must evaluate and alleviate the child's physical, psychological, and social distress

-effective palliative care requires a broad multidisciplinary approach that includes the family and makes use of available community resources; it can be successfully implemented even if resources are limited.

-it can be provided in tertiary care facilities, in community health center, and even in children's homes


_____ do not serve to hasten death, rather they provide pain and symptom management, attention to issued faced by the child and family with regard to death and dying, and promotion of optimal functioning and quality of life during the time the child had remaining.

palliative care interventions


Therapeutic management of a child with muscular dystrophy


-No effective treatment has been established
-Primary goal is to maintain function in unaffected muscles as long as possible
-Keep the child as active as possible
-Range of motion, bracing, performance of activities of daily living, surgical release of contractures as needed
-Genetic counseling for the family


Long-term goals for a child with cerebral palsy


- normalization and promotion of self-care activities that empower the child and family to achieve maximum potential.
- Live longest, most healthiest life possible


What are the five broad goals of therapy for children with Cerebral Palsy?

1. To establish locomotion, communication, and self-help skills

2. To gain optimal appearance and integration of motor functions

3. To correct associated defects as early and effectively as possible 4. To provide educational opportunities adapted to the child's needs and capabilities 5. To promote socialization experiences with other affected and unaffected children


When assessing a child with possible Compartment syndrome, what are the 6 P's that help assess the extent of injury?

1. Pain: Severe pain that is not relieved by analgesics or elevation of the limb, movement that increases pain

2. Pulselessness: Inability to palpate a pulse distal to the fracture or compartment

3. Pallor: Pale appearing skin, poor perfusion, capillary refill greater than 3 seconds

4. Paresthesia: Tingling or burning sensations

5. Paralysis: Inability to move extremity or digits

6. Pressure: Involved limb or digits may feel tense and warm; skin is tight, shiny; pressure within the compartment is elevated


Nursing objectives for a child with visual impairment

The nursing care objectives in either situation are to (1) reassure the child and family throughout every phase of treatment, (2) orient the child to the surroundings, (3) provide a safe environment, and (4) encourage independence.


Vision loss in child (not a question, just an informative card :) )

Nurses have a major role in minimizing the effects of temporary loss of vision. They need to talk to the child about everything that is occurring, emphasizing aspects of procedures that are felt or heard. They should always identify themselves as soon as they enter the room and before they approach the child.

Encourage the parents to room with their child and participate in the care. Familiar objects, such as a teddy bear or doll, should be brought from home to help lessen the strangeness of the hospital. As soon as the child is able to be out of bed, orient the child to the immediate surroundings. If the child is able to see on admission, this opportunity is taken to point out significant aspects of the room. Encourage the child to practice ambulating with the eyes closed to


Counseling a 12-year-old with scoliosis

Stephenson slides
-Concerns of body image
-Concerns of social isolation
-Concerns of prolonged treatment of condition
-Preoperative care
-Postoperative care
-Family issues

- In adolescents, this period is the one in which their identity, both physical and psychological, is formed. The identification of scoliosis as a “deformity,” in combination with unattractive braces and a significant surgical procedure, can have a negative effect on the already fragile adolescent body image.

- Nursing care of the adolescent who is facing scoliosis surgery, potential social isolation, pain, and uncertainty, not to mention misunderstood emotions and body image issues, must be evaluated from the adolescent's perspective to be successful in meeting the individual's needs.

- When a child or adolescent first faces the prospect of a prolonged period in a brace or other device, the therapy program and the nature of the device must be explained thoroughly to both the child and the parents so they will understand the anticipated results, how the appliance corrects the defect, the freedoms and constraints imposed by the device, and what they can do to help achieve the desired goal.

-Management involves the skills and services of a team of specialists, including the orthopedist, physical therapist, orthotist (a specialist in fitting orthopedic braces), nurse, social worker, and sometimes a thoracic or pulmonary specialist.


Nursing goals for an infant with a myelomeningocele


- Infection prevention
- Avoid using latex as infants w/ myelomeningocele have a high risk of developing latex allergy
- Daily head circumference measurements ( high risk for hydrocephalus)
- Cover with sterile gauze or tegaderm


Parent teaching for an infant in a Pavlik Harness


- Harness should not be removed until provider says its ok

- 23hrs a day and then off for an hour to bath

- Parents should not adjust harness

- Parents should assess child's skin at least 2-3 times daily for red areafs or skin irritation in skin folds under the straps

- Gently massage healthy skin under the straps once a day to stimulate circulation

- Always place diaper under straps

- Encourage parents to hold the infant with harness and continue care and nurturing activities


Nursing goals for an infant with a myelomeningocele

- Infection prevention


What causes hypothyroidism?

Thyroid-stimulating hormone(TSH) deficiency


Presenting symptoms of HYPOTHYROIDISM

Generalized slowing down of everything)
- Decelerated growth
- Myxedematous skin changes (dry skin, puffiness around the eys, sparse hair)
- Constipation
- Lethargy and mental decline


What is Greenstick fracture:

- bone bends causing an incomplete fracture

- kids are more prone bc there bones are soft


Parent teaching for a child with cerebral palsy

- Importance of dental hygiene
- Parents may need assistance and advice with medication administration through a gastrostomy tube to prevent clogging.
- Manual jaw control
- Car restraints especially designated for children with poor head and neck control are available and should be used.*


Signs and symptoms of Biliary Atresia

- Jaundice (starts earlier and last longer)
- dark urine
- clay colored stools
- Abdominal distention,
- Failure to Thrive
- Pruritus


Biliary Atresia

Congenital absence or obstruction of bile duct causing
- impaired drainage of bile
- Progressive inflammation and cirrhosis
of liver


Nursing care management of Biliary Atresia

- Maintain fluid and electrolyte balance
- Support nutrition
- Promote Growth and Development
- Protect from infection
- Psychosocial support


Diet for Acute Glomerulonephritis?

- Diet: moderate sodium restriction and fluid restriction

- Potassium restriction during oliguria


Laboratory findings for a child with osteomyelitis

- leukocytosis
- elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).


Planning care for a hospitalized child with nephrosis


1) Reducing excretion of urinary protein
2) Reducing fluid retention
3) Preventing infection
4) Minimizing complications related to therapies
5) Relapses & Complications


Nephrotic Syndrome (Nephrosis)

Massive proteinuria, hypoalbuminemia, hyperlipidemia and edema


What education should a nurse provide to a family of a child with a UTI

-Nurses should instruct parents to observe for signs and symptoms suggestive of UTI.
-These are not always obvious, particularly in an infant, young child, or developmentally delayed child.
-A high fever without obvious cause should be a signal to check the urine.
-Report a careful history regarding voiding habits, stooling pattern, feeding tolerance, and episodes of unexplained irritability may assist in detecting less obvious cases of UTI.


Post-op nursing interventions for a child with scoliosis

- Following surgery, patients are monitored in an acute care setting
- log rolled when changing position to prevent damage to the fusion and instrumentation.
-In some cases, an immobilization brace or cast is used postoperatively depending on the type of surgical intervention.
-Skin care is important, and pressure-relieving mattresses or beds may be needed to prevent pressure wounds


Nurse assesses a child with suspected cerebral palsy


- Child doesn't smile
- Weak head control
- Persistent Moro Reflex (startle reflex)
- Gags or chokes while eating
- Kids not meeting developmental milestones


Nursing interventions for a child with acute renal failure

-Serum potassium concentrations in excess of 7 mEq/ L is a medical emergency :
- Meticulous attention to fluid intake and output
- Monitoring fluid balance and vital signs continuously
- Maintain an optimal thermal environment
- Reduction of body temperature
- electrolyte balance maintained


Critical points in working with families with children with terminal illness

1. Initial impact
Initial impact usually occurs at the time of the child's initial diagnosis. In some situations where diagnosis is delay, parents may reach this point when they begin to recognize symptoms of illness. Other parents may reach this point when they begin to recognize the potential seriousness or difficulty of the illness. During this time period, parents must give up their preexisting view of the child and previously learned parenting behaviors, and begin developing strategies for dealing with the child,s health.

2. Increase in physical symptoms
Any time the child's physical symptoms change, the family's equilibrium may be disrupted. This disruption is particularly likely when the child,s symptoms worsen, but it may also occur if the child's symptoms improve.


assessment of child with dehydration

-weight loss
-elevated pulse
-dry mucous membranes
-decreased tears
-sunken anterior fontanel
-slow cap refill


pre-op care of a child with appendicitis:

-maintain NPO
-administer IV fluids and electrolytes as prescribed to preven dehydration
-monitor for changes in level of pain
-monitor for signs of rupture appendix and peritonitis
-administer antibiotic as prescribed
-monitor bowel sounds
-avoid laxative or enemas.


post op care of an infant with imperforate anus:

-monitor the skin for signs of infection
-the preferred position is side-lying prone position with the hope elevated
-keep the anal surgical incision clean and dry
-maintain IV fluids unti gi motility returens
-provide care for colostomy if present
-a new colostomy stoma may be red and edematous, but should decrease with time
-instruct parents ot performa anal dilation is prescribed to achieve and maintain bowel patency


arctic variant CPT1A nursing considerations

for babies and young children, caregivers must monitor and intervene when food has been lacking for long periods. Hirschfeld, a pediatrician, and other health providers have been spreading information for years about how to prevent complications like seizures — caregivers should make sure the babies and children take in breast milk, formula or other glucose-containing liquids, by intravenous means if necessary, according to the advice.


(arctic variant CPT1A)

If children go too long without eating or drinking enough glucose-containing fluids (such as when they are sick), they can have an illness called a metabolic crisis. Some of the first signs of a metabolic crisis are:

extreme sleepiness
irritable mood
poor appetite


If a metabolic crisis is not treated, a child with CPT1A arctic variant can develop:

low blood sugar (hypoglycemia)
high levels of ammonia in the blood
breathing problems
coma, sometimes leading to death


arctic variant CPT1A

(just a card about arctic variant CPT1A)

If treated quickly and appropriately, these symptoms can be reversed. However, if a child has too many metabolic crises, they could develop brain damage. This brain damage can result in learning problems or intellectual disabilities. Therefore, it is important that infants and children with CPT1A arctic variant receive prompt treatment if they exhibit symptoms of metabolic crisis. Treatment should help to avoid potential long-term effects on development.


lab changes in a child with frequent emesis

-low potassium
-metabolic alkalosis


lab values for a child with appendicitis

-The WBC count becomes elevated

-Elevated C-reactive protein (CRP)


hypotonic dehydration

Greater loss of Na+ than water causing hypotonic serum

Fluid shifts from intravascular to interstitial space causing signs of severe dehydration

May cause shock

Serum Na+ <130

Causes: vomiting, diarrhea, inappropriate fluid administration


Therapeutic management of a fracture

Therapeutic Management The goals of fracture management are: • To regain alignment and length of the bony fragments (reduction) • To retain alignment and length (immobilization) • To restore function to the injured parts • To prevent further injury and deformity The majority of children's fractures heal well, and nonunion is rare. Fractures are splinted or casted to immobilize and protect the injured extremity. Children with displaced fractures may have immediate surgical reduction and fixation (internal or external) rather than being immobilized by traction ( Fig. 29-4 ). This practice is more common and holds true for all types of fractures, including femur fractures, although there is variation based on provider preference and institutional practice. Some conditions require immediate medical attention, including open fractures, compartment syndrome, fractures associated with vascular or nerve injury, and joint dislocations that are unresponsive to reduction maneuvers.