Week 3 Content Flashcards
1
Q
6-12 y.o
AT this time Immunizations should be up to date.
They are given for catch up situations and customized to each child at this point.
Consult the CDC for __________ scheduling
A
AT this time Immunizations should be up to date.
They are given for catch up situations and customized to each child at this point.
Consult the CDC for “catch up” scheduling
2
Q
6-12 y.o Anticipatory Guidance - Healthy Lifestyle
- Fruit, Veggies, Whole Grains, Lean Meats and Fish
- ↑Water, ↓ Juice, ↓Cola, ↓Processed
- Activity (exercise) ___ min day
- Limit Screen Time to ___ hours (quality) screen time/day
A
- Fruit, Veggies, Whole Grains, Lean Meats and Fish
- ↑Water, ↓ Juice, ↓Cola, ↓Processed
- Activity (exercise) 60 min day
- Limit Screen Time to 2 hours (quality) screen time/day
3
Q
6-12 y.o Anticipatory Guidance cont.
- First teeth come in about age __
- Brush teeth x2 /day
- _______ safety
- Helmets
- Water Safety
- ________ safety
A
- First teeth come in about age 6
- Brush teeth x2 /day
- Traffic safety
- Helmets
- Water Safety
- Firearm safety
4
Q
School Age-Adolescent Growth: Tanner puberty scale
A
5
Q
6-12 y.o theories
SOCIAL - Erikson’s _________________
COGNITIVE - Piaget’s _____________
A
SOCIAL - Erikson’s Industry Vs Inferiority
COGNITIVE - Piaget’s Concrete Operational Phase
6
Q
Erikson—SOCIAL - Industry vs Inferiority
They like to do and accomplish
Example: Need to be __________ in Academic and Social Demands
Children who are encouraged and commended by parents and teachers develop a feeling of __________ (industry) and belief in their abilities.
Those who receive little or no encouragement from parents, teachers, or peers will ______ their ability to be successful and feel inferior
A
They like to do and accomplish
Example: Need to be Successful in Academic and Social Demands
Children who are encouraged and commended by parents and teachers develop a feeling of competence (industry) and belief in their abilities.
Those who receive little or no encouragement from parents, teachers, or peers will doubt their ability to be successful and feel inferior
7
Q
Piaget—Cognitive - Concrete Operational Phase - 7-12 years
Decreased Egocentrism and Increased Importance in ____________
Can put themselves in the “shoes of others”
Can understand what someone else is _______________
A
Decreased Egocentrism and Increased Importance in Relationships
Can put themselves in the “shoes of others” Can understand what someone else is going through
8
Q
School Age: CARE ISSUES
Respect Privacy
DIRECT STRAIGHT FORWARD :Explanation of All procedures is IMPORTANT
Can learn from verbal explanations as well as pictures and brochures
Benefits from handling medical equipment
PAIN: Wong Baker Faces Until about Age 9
Numbers 1-10 Scale when able to ___________ the concept
A
understand
9
Q
Pain Rating Scales
A
10
Q
Use of Numbers Pain Scale 9 years and up
- May be better to substitute the word pain with “ouch or hurt”
- Mistake to say “on a scale of 1-10”don’t forget that _____ equals no pain!
- Another mistake is to say that 10 is the worst pain you have ever had… should be the worst you can _________.
A
- May be better to substitute the word pain with “ouch or hurt”
- Mistake to say “on a scale of 1-10”don’t forget that zero equals no pain!
- Another mistake is to say that 10 is the worst pain you have ever had… should be the worst you can imagine.
11
Q
CAPILLARY REFILL TIME > 2 SECONDS
Decreased or Compromised Blood flow to Extremity – Can Cause Vascular ischemia to tissues
- Decreased _______________
Depressed Heart function (sick heart muscle)
Hypovolemia (loss of blood or fluid)
Vasoconstriction (cold, or meds like Epinephrine)
-Restricted ______________
Compartment Syndrome-
Medical device too tight (Cast, Tape)
Pressure (bed surfaces, medical devices)
A
- Decreased Cardiac Output
Depressed Heart function (sick heart muscle)
Hypovolemia (loss of blood or fluid)
Vasoconstriction (cold, or meds like Epinephrine)
-Restricted Blood Flow
Compartment Syndrome-
Medical device too tight (Cast, Tape)
Pressure (bed surfaces, medical devices)
12
Q
RESTRICTED BLOOD FLOW TO EXTREMITY DUE TO INJURIE/FRACTURES/CAST
–Perform Neurovascular Checks
5 Ps
CSM assessment- CIRCULATION, SENSORY, MOVEMENT
–Check for swelling
–Monitor Pain
A
–Perform Neurovascular Checks
5 Ps
CSM assessment- CIRCULATION, SENSORY, MOVEMENT
–Check for swelling
–Monitor Pain
13
Q
ASSESS 5 P’S - CSM
A
*Pain
*Pallor (color)
*Pulselessness (circulatory) C
*Paresthesia (sensory) S
*Paralysis (motor) M
14
Q
COMPARTMENTAL SYNDROME
Progressive decrease in __________ __________ resulting from increased pressure from edema (swelling) or bleeding that presses on tissues and vessels.
Causes compromised _________. If not treated can result in permanent nerve and vascular damage and potential need for amputation.
A
Progressive decrease in tissue perfusion resulting from increased pressure from edema (swelling) or bleeding that presses on tissues and vessels.
Causes compromised circulation. If not treated can result in permanent nerve and vascular damage and potential need for amputation.
15
Q
COMPARTMENTAL SYNDROME- CAN ALSO BE CAUSED BY ___________ AFTER A
FRACTURE
A
BLEEDING
16
Q
FRACTURES IN THE INFANT AND SMALL CHILD
- Fractures common in children- ___% of all injuries in children are fractures
- Infancy/toddler/preschool– ______ trauma, MVA, child ______ (twisting, rough handling, pulling)
- School age/Adolescents ______, MVA, _______ injuries, falls
- Small child with multiple fractures at varied stages of healing warrants investigation for ______
A
- Fractures common in children-15% of all injuries in children are fractures
- Infancy/toddler/preschool– birth trauma, MVA, child abuse (twisting, rough handling, pulling)
- School age/Adolescents sports, MVA, bike injuries, falls
- Small child with multiple fractures at varied stages of healing warrants investigation for abuse
17
Q
EPIPHYSEAL FRACTURES
- ___________ plate weakest point of long bones
- Normally heals quickly and completely
- Risk of damage to growth plate
- Early identification critical to minimize growth problems and deformities
A
Epiphyseal
18
Q
COMPLICATIONS OF FRACTURES
* __________ impairment
* ______ compression
* _____________ syndrome
* Epiphyseal damage
* Non union or malunion of bone
* Osteomyelitis
* Pulmonary emboli
* Shock hypovolemia
A
- Circulatory impairment
- Nerve compression
- Compartment syndrome
- Epiphyseal damage
- Non union or malunion of bone
- Osteomyelitis
- Pulmonary emboli
- Shock hypovolemia
19
Q
SKIN TRACTION FOR FRACTURES
Restores Tension to Surrounding Tissues
__________ fracture
Decreases _____
Helps ________ the bone
Usually applied in ED temporarily waiting __________
A
Restores Tension to Surrounding Tissues
Stabilizes fracture
Decreases Pain
Helps realign the bone
Usually applied in ED temporarily waiting surgery
20
Q
_______TRACTION
A type of skin traction that is widely used for femoral, hip, and acetabular fractures
A
BUCK’S
21
Q
DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)
- Abnormal development of the femoral head in the _________
- Wide range of abnormal development of the hip leading to hip _________
- Hip instability occurs in _____% of term babies
- Treatment required because of possibility of a limp, constant pain, impaired mobility later in life, early arthritis
A
- Abnormal development of the femoral head in the acetabulum
- Wide range of abnormal development of the hip leading to hip instability
- Hip instability occurs in 1 to 2% of term babies
- Treatment required because of possibility of a limp, constant pain, impaired mobility later in life, early arthritis
22
Q
DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) ETIOLOGY
Exact cause unknown
↑ Risk
* 80% ________
* Left hip most common
* Intrauterine position
* First born
* Breech birth
A
Exact cause unknown
↑ Risk
* 80% female
* Left hip most common
* Intrauterine position
* First born
* Breech birth
23
Q
DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) DIAGNOSE
Infant
* Positive _______ & _______ tests (.>2 months of age will not detect)
* Unequal folds of skin on buttock and thighs
* Limited abduction of affected hip
* Unequal leg lengths
Older child
* Limp on affected side
* Trendelenburg sign-pelvis dips when walking or standing to maintain balance
A
Ortolani and Barlow
24
Q
DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) MANAGEMENT: 0 TO 6 MONTHS
Therapy: Positioning legs in flexed abducted position
(1) Dynamic splinting: _____ ______ Worn continuously for 2- 3 months until hip stable
- Straps checked every 1 to 2 weeks for adjustment Improper application can lead to
femoral nerve palsy and avascular necrosis femoral head
A
Pavlik harness
25
DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) MANAGEMENT: 6 TO 18 MONTHS
* (2) Gradual reduction by ______ ________ for 3 weeks
* Used more commonly in Europe and Asia than US.
Bryant traction
26
DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) MANAGEMENT cont.
(3) * ________ necessary if splinting and traction are not successful
* Closed/open reduction under anesthesia
* Hip spica cast for 3 months
Surgical
27
NURSING PLAN/ INTERVENTIONS - DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)
* Perform post operative care
* Assess vital signs
* Check cast for ____________ & __________
* Perform ____________ ___________ of extremities,
* Pain Management
* Promote respiratory hygiene
* Teach family cast care for when child goes home
* Perform post operative care
* Assess vital signs
* Check cast for drainage and bleeding
* Perform neurovascular assessment of extremities,
* Pain Management
* Promote respiratory hygiene
* Teach family cast care for when child goes home
28
_______ Cast
Heavier
Cheaper
Used mostly for splints
NO WATER will dissolve edges and lead to more potential to rub skin
_________ cast
Lighter
More durable
More expensive
Still should not get wet because the padding underneath is not water proof
Plaster Cast
Heavier
Cheaper
Used mostly for splints
NO WATER will dissolve edges and lead to more potential to rub skin
Fiberglass cast
Lighter
More durable
More expensive
Still should not get wet because the padding underneath is not water proof
29
PLASTER CAST SPLINT
Allows for __________ without compromising circulation of extremity, after a day or 2 a complete cast can then be applied
swelling
30
Scoliosis & 2 types
* A lateral curvature of the spine of > ___ degrees
* ___________ Scoliosis :Most common kind- start to screen age 10 does have a genetic component
* __________: Caused by conditions like Cerebral Palsy, Spina Bifida, Musculodystrophy due to Impaired ability to control muscles that support the spine
* A lateral curvature of the spine of > 10 degrees
* Idiopathic Scoliosis :Most common kind- start to screen age 10 does have a genetic component
* Neuromuscular: Caused by conditions like Cerebral Palsy, Spina Bifida, Musculodystrophy due to Impaired ability to control muscles that support the spine
31
Screening Assessment for scoliosis
Most commonly seen in _________ ages 10 to 15
Physical exam
* Asymmetry of the height of shoulders, hips and scapular shapes when standing
* Asymmetry of ribs and flanks with bend at the waist
* Twist to evaluate flexibility of curve
X-ray of spine to measure curve
Most commonly seen in females ages 10 to 15
Physical exam
* Asymmetry of the height of shoulders, hips and scapular shapes when standing
* Asymmetry of ribs and flanks with bend at the waist
* Twist to evaluate flexibility of curve
X-ray of spine to measure curve
32
Adams Forward Bend Test
[don't need to know for test]
33
Screening [scoliosis]
* Early detection increases the chance of ________ rather than surgery
* AAP recommendation is for scoliosis screening to be done by primary care practitioner
* Early detection increases the chance of bracing rather than surgery
* AAP recommendation is for scoliosis screening to be done by primary care practitioner
34
Scoliosis treatment depends on the severity of curvature and risk of progression
* Less than 30 degrees-monitor, ___________
* Moderate 30 to 45 degrees-__________
* Severe > 50 degrees- _____________
Scoliosis treatment depends on the severity of curvature and risk of progression
* Less than 30 degrees-monitor, exercise
* Moderate 30 to 45 degrees-bracing
* Severe > 50 degrees-spinal rods
35
Severe scoliosis can lead to diminishing _____ capacity, pressure on the ______, restricted physical activities, cosmetic and emotional factors
Severe scoliosis can lead to diminishing lung capacity, pressure on the heart, restricted physical activities, cosmetic and emotional factors
36
Scoliosis - Bracing does not correct curve, but can slow or stop ____________
Teach application of Boston brace
* Wear ___ hours per day
* Wear T-shirt under brace to decrease irritation
* Check skin for signs of irritation
* Suggest clothing modifications to camouflage brace
* Daily ___________ to prevent atrophy of spinal and abdominal muscle
* Plan ways of improving self-concept
Scoliosis - Bracing does not correct curve, but can slow or stop progression
Teach application of Boston brace
* Wear 23 hours per day
* Wear T-shirt under brace to decrease irritation
* Check skin for signs of irritation
* Suggest clothing modifications to camouflage brace
* Daily exercises to prevent atrophy of spinal and abdominal muscle
* Plan ways of improving self-concept
37
Scoliosis- Operative Management
38
Positioning of Patient in OR for Spinal Surgery:
Procedure takes 6-8 hours
39
Scoliosis PAIN
Originates from: vertebrae, intervertebral disc, ligaments dura, nerve root sleeves, facia and muscles
Post op: Mechanical irritation from hardware and post op inflammation
Intensity of Pain directly related to how many vertebra involved
Originates from: vertebrae, intervertebral disc, ligaments dura, nerve root sleeves, facia and muscles
Post op: Mechanical irritation from hardware and post op inflammation
Intensity of Pain directly related to how many vertebra involved
40
Scoliosis Post-operative Nursing Care
Pain management
Note: prior to skin incision in OR Intrathecal Morphine and Bupivacaine is injected; Usually wears off early next morning post op day 1
Patient Controlled Analgesia – initiated post op.
FIRST: Morphine, Fentanyl or Dilaudid started IV continuously with a PCA dose q 8-10 min. Reassess frequently
Pain management
Note: prior to skin incision in OR Intrathecal Morphine and Bupivacaine is injected; Usually wears off early next morning post op day 1
Patient Controlled Analgesia – initiated post op.
FIRST: Morphine, Fentanyl or Dilaudid started IV continuously with a PCA dose q 8-10 min. Reassess frequently
41
Post-op scoliosis
PAIN MANAGEMENT: ___________ Results in ↓ use of opioids
* Usually 1 day of PCA w/ continuous amt of narcotic with rescue dosing q 8-10 min
* Second: When able to tolerate POs
* --add PO narcotic- Oxycodone (Percocet)
-discontinue continuous infusion on PCA
- keep rescue IV lock out on PCA 10-15 min
-add non narcotic pain medications
IV ________ can be started 48 hours after Surgery: Ketorolac (Toradol) (< 5 days of use)
___________ - especially good for nerve pain, such as burning, shooting or stabbing pain.
PAIN MANAGEMENT: Multimodal Results in ↓ use of opioids
* Usually 1 day of PCA w/ continuous amt of narcotic with rescue dosing q 8-10 min
* Second: When able to tolerate POs
* --add PO narcotic- Oxycodone (Percocet)
-discontinue continuous infusion on PCA
- keep rescue IV lock out on PCA 10-15 min
-add non narcotic pain medications
IV NSAIDS can be started 48 hours after Surgery: Ketorolac (Toradol) (< 5 days of use)
Gabapentin- especially good for nerve pain, such as burning, shooting or stabbing pain.
42
Side effects of NSAIDs
________ dysfunction
Risk of __________
Gastric Ulceration
______ toxicity
Platelet dysfunction
Risk of hemorrhage
Gastric Ulceration
Renal toxicity
43
NSAIDs
– Ketorolac (Toradol)
– Ibuprofen (Motrin)
– Ketorolac (Toradol)
– Ibuprofen (Motrin)
44
Scoliosis post-op DRESSING
* Inspect Q 2 hours with _________ turning
* Only change if ________ with drainage
* Remove dressing around post op day 4
* Sutures removed around post ofp day 10
* Inspect Q 2 hours with log roll turning
* Only change if saturated with drainage
* Remove dressing around post op day 4
* Sutures removed around post ofp day 10
45
IMMOBIlITY Consequences
--High potential for ______ breakdown
--_________ (Incentive Spirometer)
--Turn q ___ hours
--Log rolling to prevent damage to spinal fusion
--Antiembolism stockings (prevent thrombosis)
--Ambulate as early as possible
--High potential for skin breakdown
--Atelectasis (Incentive Spirometer)
--Turn q two hours
--Log rolling to prevent damage to spinal fusion
--Antiembolism stockings (prevent thrombosis)
--Ambulate as early as possible
46
Scoliosis Post op care continued
* Post-op ________ a rare risk
* Check peripheral CSM as ordered
* Keep _____ for 12 hours
* Sit up in bed POD 1, dangle POD 2, out of bed POD 3
* Post-op paralysis a rare risk
* Check peripheral CSM as ordered
* Keep flat for 12 hours
* Sit up in bed POD 1, dangle POD 2, out of bed POD 3
47
Log rolling for 5 days
* Requires __ or more persons
* Client is moved to side of bed with _______
* Client is moved in simultaneous motion, maintaining straight spine
* Pillows arranged to maintain alignment
* Requires 2 or more persons
* Client is moved to side of bed with sheet
* Client is moved in simultaneous motion, maintaining straight spine
* Pillows arranged to maintain alignment
48
Scoliosis post-op
Potential for ___ dysfunction
* Assess return of bowel function
* Constipation common
* Paralytic ileus possible (requires NG tube)
Potential for ____ dysfunction
* Foley catheter
* Urine retention due to narcotics ,
* ↓uop due to renal hypoperfusion in OR
* Strict I and O; maintain fluid balance
Potential for GI dysfunction
* Assess return of bowel function
* Constipation common
* Paralytic ileus possible (requires NG tube)
Potential for GU dysfunction
* Foley catheter
* Urine retention due to narcotics ,
* ↓uop due to renal hypoperfusion in OR
* Strict I and O; maintain fluid balance
49
Scoliosis post-op Discharge teaching
Caution against adding Tylenol to some pain meds that may have ________ as a component.
______ worn for several months until fusion stable
May need home schooling
Encourage strategies to promote self esteem
Caution against adding Tylenol to some pain meds that may have Tylenol as a component.
Brace worn for several months until fusion stable
May need home schooling
Encourage strategies to promote self esteem
50
Pediatric patients metabolize meds differently because of differences in renal excretion and hepatic metabolism ( leads to higher risks of drug ________ )
toxicity
51
Peds- _________ ________ also not fully functional; may effect drug activity in one of two ways: either by changing the effective concentration of the drug at its site of action or by changing the rate at which the drug is eliminated, thus affecting the length of time for which effective concentrations are maintained.
Protein binding
52
Pain management - _________
-Sucrose produces analgesia through both endogenous opioid and non opioid pathways
-Taste receptors important so place on tongue or buccal surface
-Non nutritive sucking (pacifier) helps after
SUCROSE
53
Tootsweet- ____% sucrose soln in single dose container
24
54
Sucrose for pain used for -
heel sticks
venipuncture
Immunizations
Dressing changes
In combo for more painful procedures
LP (local lidocaine creams)
Circumcisions (use nerve blocks too)
16-19 month immunizations
heel sticks
venipuncture
Immunizations
Dressing changes
In combo for more painful procedures
LP (local lidocaine creams)
Circumcisions (use nerve blocks too)
16-19 month immunizations
55
Tylenol : Acetominophin
PO: ______ mg/kg q 4-6 hours
MAX dose < 2 years of age 60mg/kg/24 hours
> 2 years of age 75mg/kg/24 hours
IV Tylenol V acetaminophen (Ofirmev®) is >1000 times more expensive than oral acetaminophen and is therefore restricted to patients who are absolutely NPO. According to the majority of available evidence, IV acetaminophen has not demonstrated superiority over oral acetaminophen for pain or fever control.
10-15
56
NSAIDS
*Nonsteroidal anti-inflammatory drug i.e. Ibuprofen, Motrin, Advil
*Interfere with production of __________
*Onset 30min-1hr peak 1-2 hr
*Side effects: stomach upset
*Nonsteroidal anti-inflammatory drug i.e. Ibuprofen, Motrin, Advil
*Interfere with production of prostaglandin
*Onset 30min-1hr peak 1-2 hr
*Side effects: stomach upset
57
Ibuprofen
-Avoid in infants < ___ months of age
- PO dosing ______ mg/kg every 6-8 hours
400 mg max per dose
40mg/kg/24 hours
-Avoid in infants < 6 months of age
- PO dosing 10-15 mg/kg every 6-8 hours
400 mg max per dose
40mg/kg/24 hours
58
Ketorolac (Toradol)
IV NSAID
- Use for less than 5 days. Increased risk of renal and other side effects after this. (interstitial nephritis- inflammation of kidney tissue)
- Monitor ______________ & __________ before giving
- Effects on platelet adhesion and aggregation may prolong bleeding time.
- IV dose 0.5 – 1.0 mg/kg/dose q 6-8 hours
Max 30 mg dose
Max 40mg/kg/24 hours
renal function and platelets
59
The term equianalgesia, meaning “approximately equal analgesia,” refers to the doses of various opioid analgesics that are estimated to provide the _________________
same pain relief.
60
Fentanyl- quicker onset but ________ lasting.. But note that at steady state, slow elimination from tissue can lead to prolonged half-life. Use for short procedures:
Fentanyl patches are also available but NOT FOR _______ PAIN- FDA warning that deaths have occurred with misuse. Baseline opioid need must be known and covered to corresponding fentanyl patch
Fentanyl- quicker onset but shorter lasting.. But note that at steady state, slow elimination from tissue can lead to prolonged half-life. Use for short procedures:
Fentanyl patches are also available but NOT FOR ACUTE PAIN- FDA warning that deaths have occurred with misuse. Baseline opioid need must be known and covered to corresponding fentanyl patch
61
Morphine
-Most widely studied of opioids
- Metabolized liver, excreted kidneys
- Mean elimination half-life following a single dose can be 2.6 to 14 hours
- Neonates less than 40 weeks ( babies born early) have longer elimination half lives
- Concurrent illness can impact morphine clearance and lead to accumulation of metabolites (ie renal disease)
-Most widely studied of opioids
- Metabolized liver, excreted kidneys
- Mean elimination half-life following a single dose can be 2.6 to 14 hours
- Neonates less than 40 weeks ( babies born early) have longer elimination half lives
- Concurrent illness can impact morphine clearance and lead to accumulation of metabolites (ie renal disease)
62
Hydromorphone: Dilaudid
- 5-7 times more potent than morphine
- IV, POs
- Often thought to have ___________ as side effect versus morphine.
Dosing:
PO 0.03 - 0.08 mg/kg/dose Q4-6
IV 0.01 mg/kg/dose Q4-6
less pruritus
63
Opioid Narcotics Only offered PO
- Oxycodone- Percocet
- OxyContin- (extended release Oxycodone _______ ______)
- Hydrocodone- Vicodin
NEVER crush
64
Narcotic Side effects
- Potential ________ Depression
- Sedation
- Urinary _________
- Constipation
- Nausea ________
- Puritis
- Dizzyness
- Dry Mouth
- Potential Respiratory Depression
- Sedation
- Urinary Retention
- Constipation
- Nausea Vomitting
- Puritis
- Dizzyness
- Dry Mouth
65
Changing route of pain meds
With opioids and converting the oral to IV or IV to oral change is not always one to one
For example 1 mg of IV morphine equals 3 mg of oral morphine so THE _____ DOSE WILL BE GREATER THAN THE IV DOSE IN THIS EXAMPLE
ORAL
66
Pyloric Stenosis
__________ of the pyloric canal; the sphincter (circular muscle of the pylorus) hypertrophies to twice the normal size
Narrowing of the pyloric canal; the sphincter (circular muscle of the pylorus) hypertrophies to twice the normal size
67
Pyloric Stenosis
* ________ non-bilious, non-bloody, progressively worsening
* Hungry, fretful infant
* Weight _____
* Dehydration
* Metabolic alkalosis
↓sodium and
↓potassium
* Olive shaped mass in __________ quad of abdomen
* Vomiting non-bilious, non-bloody, progressively worsening
* Hungry, fretful infant
* Weight loss
* Dehydration
* Metabolic alkalosis
↓sodium and
↓potassium
* Olive shaped mass in upper right quad of abdomen
68
Preoperative care for pyloromyotomy
* Administer IV _____ and correct electrolytes
* ______ daily, monitor I & O
* Provide small, frequent feedings
* Prepare family for ______:
* (prognosis excellent)
Postoperative care
* Continue Maintenance IV fluids
* Start small oral feedings with _________ replacement solution start usually 4 to 6 hours
* Position on right side in semi-Fowler position after eating
* Burp frequently
* Weigh daily,
* Strict I & O
Preoperative care for pyloromyotomy
* Administer IV fluids and correct electrolytes
* Weight daily, monitor I & O
* Provide small, frequent feedings
* Prepare family for surgery:
* (prognosis excellent)
Postoperative care
* Continue Maintenance IV fluids
* Start small oral feedings with electrolyte replacement solution start usually 4 to 6 hours
* Position on right side in semi-Fowler position after eating
* Burp frequently
* Weigh daily,
* Strict I & O
69
Intussusception
* Child under 1 year of age
* Acute _________ abdominal pain
* Screaming “bloody murder” with legs drawn up to abdomen
* Vomiting
* Currant jelly stools (_______ & ______)
* Child under 1 year of age
* Acute intermittent abdominal pain
* Screaming “bloody murder” with legs drawn up to abdomen
* Vomiting
* Currant jelly stools (blood and mucus)
70
Intussusception
* __________ of part of the intestine into another part of the intestine
* Partial to complete bowel obstruction occurs
* Blood vessels become trapped in the telescoping bowel causing _______
* Usually 2 to 36 months old
* Cause not well understood: infections?
* __________ intervention is needed
* Telescoping of part of the intestine into another part of the intestine
* Partial to complete bowel obstruction occurs
* Blood vessels become trapped in the telescoping bowel causing necrosis
* Usually 2 to 36 months old
* Cause not well understood: infections?
* Emergency intervention is needed
71
Bowel Obstruction and Perforation
Monitor bowel __________:
* Fever
* Severe abdominal pain and tenderness
* Abdomen distension
* Nausea and vomiting
Monitor for _______ _____ 2ndary to Perforation
* Tachycardia,
* Poor perfusion with weak pulses, increased capillary refill
* Tachypnea
* Decreased urine output
* Hypotension (due to bacteria from intestines in peritoneum)
Monitor bowel perforation:
* Fever
* Severe abdominal pain and tenderness
* Abdomen distension
* Nausea and vomiting
Monitor for Septic Shock 2ndary to Perforation
* Tachycardia,
* Poor perfusion with weak pulses, increased capillary refill
* Tachypnea
* Decreased urine output
* Hypotension (due to bacteria from intestines in peritoneum)
72
Bowel Obstructionand Perforation
Prepare family for emergency intervention
Treated with ________ _______ or air contrast enema, success rate over 80%, 10% reoccur within 24 hours,
if not successful, surgery necessary and temporary colostomy
barium enema
73
Cleft Lip and Palate
* Malformations of the face and oral cavity that seem to be multifactorial hereditary
origin
* Cleft lip is readily apparent
* Cleft palate is assessed at birth for all infants.
* Cleft lip repaired ______ months
* Cleft palate repaired _______ months to age to minimize speech impairment
* Malformations of the face and oral cavity that seem to be multifactorial hereditary
origin
* Cleft lip is readily apparent
* Cleft palate is assessed at birth for all infants.
* Cleft lip repaired 2 to 3 months
* Cleft palate repaired 9 to 18 months to age to minimize speech impairment
74
Cleft Lip and Palate
* Difficulty __________ & ____________
* Typical parent and family reactions to a child with obvious malformations such as cleft lip or palate are guilt, disappointment, grief, sense of loss and anger
sucking and swallowing
75
Cleft Lip and Palate
* Inform family about _______ option
* In newborn period, assist with feeding
* Feed in upright position Feed slowly with frequent burping
* Use soft, large nipples (special needs nipple), prosthetic palate
* Support mother’s breast feeding if possible
* Inform family about surgical option
* In newborn period, assist with feeding
* Feed in upright position Feed slowly with frequent burping
* Use soft, large nipples (special needs nipple), prosthetic palate
* Support mother’s breast feeding if possible
76
Cleft Lip and Palate Postoperative care
Maintain ______ _______
* Proper positioning for mucus drainage, elevate head of bed 30 degrees
* Remove oral secretions carefully with bulb syringe or soft suction set
Protect _______ ______
* Apply elbow restraints
* Minimize crying to prevent strain on lip suture line
Maintain patent airway
* Proper positioning for mucus drainage, elevate head of bed 30 degrees
* Remove oral secretions carefully with bulb syringe or soft suction set
Protect surgical site
* Apply elbow restraints
* Minimize crying to prevent strain on lip suture line
77
HISCHPRUNG’S Disease – Mega Colon
Congenital
* Absence of autonomic parasympathetic ________ cells in distal portion of colon
and rectum
* Common with Down’s Syndrome
* A lack of ________ in the area of the colon where the ganglion cells are of the bowel
Congenital
* Absence of autonomic parasympathetic ganglion cells in distal portion of colon
and rectum
* Common with Down’s Syndrome
* A lack of peristalsis in the area of the colon where the ganglion cells are of the bowel
78
Surgery for Hirshprung’s
-Correction involves a series of _________
-Remove part of intestines and rectum involved (determined by biopsy)
-A temporary colostomy
-Later, pull large intestines down and a re-anastomosis and closure of the colostomy
surgeries
79
Gastroesophageal Reflux Disease (GERD)
* Passive regurgitation of stomach content due to incompetence of the lower esophageal ________
* Incidence and etiology
* Physiologic - very common, peaks at ___ months; resolves by 12 months. Not considered a problem unless child has frequent _________ and/or complications
* Pathologic - associated with irritability, pain, esophagitis, esophageal bleeding, FTT, RAD, near miss SIDS or aspiration pneumonia
* Passive regurgitation of stomach content due to incompetence of the lower esophageal sphincter
* Incidence and etiology
* Physiologic - very common, peaks at 4 months; resolves by 12 months. Not considered a problem unless child has frequent regurgitation and/or complications
* Pathologic - associated with irritability, pain, esophagitis, esophageal bleeding, FTT, RAD, near miss SIDS or aspiration pneumonia
80
Gastroesophageal Reflux Disease
* _________ predisposition
* Transient relaxation of lower esophageal sphincter
* Resulting from increased intra-abdominal _________ from (e.g., position; overfeeding)
* Pathophysiology: gastric contents backup into esophagus; acidic content leads to inflammation of esophagus; loss of nutrients leads to malnutrition
* Genetic predisposition
* Transient relaxation of lower esophageal sphincter
* Resulting from increased intra-abdominal pressure from (e.g., position; overfeeding)
* Pathophysiology: gastric contents backup into esophagus; acidic content leads to inflammation of esophagus; loss of nutrients leads to malnutrition
81
Gastroesophageal Reflux Signs and symptoms:
* ____________, especially after eating
* Signs of esophagitis: ________, arching back, choking, gagging, feeding aversion
* Complaints of chest and abdominal pain in older children
* Some children with chronic disease has this ( more complicated)
* Regurgitation, especially after eating
* Signs of esophagitis: irritability, arching back, choking, gagging, feeding aversion
* Complaints of chest and abdominal pain in older children
* Some children with chronic disease has this ( more complicated)
82
Gastroesophageal Reflux Nursing Plans and Interventions
Conservative:
* Diet (_________ formula, continue breastfeeding, smaller, more frequent feedings)
* Positioning (________ head of bed slightly; prone position OK while child is awake or being carried, supine position while asleep even with significant GER)
Conservative:
* Diet (thicken formula, continue breastfeeding, smaller, more frequent feedings)
* Positioning (elevate head of bed slightly; prone position OK while child is awake or being carried, supine position while asleep even with significant GER)
83
Gastroesophageal Reflux Nursing Plans and Interventions
Medications:
* ________ (temporary relief; long term not recommended; decrease acid effect)
* _________________ (recommended as first line treatment; decreases gastric acid production).
* ________ (fundoplication): in cases unresponsive to conservative treatment or children with anatomical defect
* Antacids (temporary relief; long term not recommended; decrease acid effect)
* Proton pump inhibitor (recommended as first line treatment; decreases gastric acid production).
* Surgery (fundoplication): in cases unresponsive to conservative treatment or children with anatomical defect
84
Obesity
* BMI is acceptable way to determine obesity for children 2 years of age and older, > 85% overweight, > 95% obese
* Leads to adult obesity with increased risks of __________ issues and type 2 diabetes
* __________ disproportionally at risk
* ___________ obesity is the highest predictor of childhood obesity
* Excessive caloric intake, decreased physical activity, decreased resting metabolic rate
* BMI is acceptable way to determine obesity for children 2 years of age and older, > 85% overweight, > 95% obese
* Leads to adult obesity with increased risks of cardiovascular issues and type 2 diabetes
* Minorities disproportionally at risk
* Parental obesity is the highest predictor of childhood obesity
* Excessive caloric intake, decreased physical activity, decreased resting metabolic rate
85
Obesity
Prognosis: Poor for long-term weight loss
Can derive significant health benefits from modest weight lost
Best results
* ________ support
* Treat as chronic condition
* Diet restriction and increased activity level
* ________ weight goals
Obesity
Prognosis: Poor for long-term weight loss
Can derive significant health benefits from modest weight lost
Best results
* Family support
* Treat as chronic condition
* Diet restriction and increased activity level
* Realistic weight goals
86
Obesity Complications
* Sleep apnea
* Heart disease
* Hypertension
* DM type 2
* Slipped capital femoral epiphysis
* Hyperlipidemia
* Depression
* Sexual development
Obese children at 2 years more likely to be obese adults, contribute to 5 year shorter life expectancy
* Sleep apnea
* Heart disease
* Hypertension
* DM type 2
* Slipped capital femoral epiphysis
* Hyperlipidemia
* Depression
* Sexual development
Obese children at 2 years more likely to be obese adults, contribute to 5 year shorter life expectancy
87
Obesity: Management
* Weight maintenance vs. weight loss
Goal: do not attempt to lose weight, __________ weight so _______ can catch up
* Family - centered treatment
* Establish health eating habits early
* Adult responsibility (to provide healthful foods in positive environment)
* Child responsibility (to eat)
* Authority and pressure to _________ are counter-productive; do not push a child to eat “good food” or forbid a child from eating “bad food.”
Goal: do not attempt to lose weight, maintain weight so height can catch up
* Family - centered treatment
* Establish health eating habits early
* Adult responsibility (to provide healthful foods in positive environment)
* Child responsibility (to eat)
* Authority and pressure to “eat right” are counter-productive; do not push a child to eat “good food” or forbid a child from eating “bad food.”
88
Obesity Nursing Plans and Interventions
* Increase ________ level
* Decrease high-fat and high calorie foods
* Support for lifestyle changes
* Bariatric surgery
* Prevention: ___________ lowers risk of obesity
* Increase activity level
* Decrease high-fat and high calorie foods
* Support for lifestyle changes
* Bariatric surgery
* Prevention: Breast-feeding lowers risk of obesity
89
After 4 days of toradol, it may interfere with
platelet function
90
Pediatric _______
* Primary cause of morbidity and mortality in the pediatric population
* The leading cause of death from 6 months – young adulthood
* Unintentional injury and death in children has reached epidemic proportions
* Trauma is preventable...it is not an accident
Pediatric Trauma
* Primary cause of morbidity and mortality in the pediatric population
* The leading cause of death from 6 months – young adulthood
* Unintentional injury and death in children has reached epidemic proportions
* Trauma is preventable...it is not an accident
91
Kids are Different - The P3 Differential
* Physically: _______ body size
* Physiologically: _________ organ and immune systems
* Psychologically: Cognitively, developmentally and emotionally __________ with total dependence upon their care givers
* Physically: smaller body size
* Physiologically: immature organ and immune systems
* Psychologically: Cognitively, developmentally and emotionally immature with total dependence upon their care givers
92
Pediatric Trauma Assessment- Remember the ABC’s...
Primary Assessment
* A – Airway with simultaneous cervical spine protection
* B – Breathing
* C – Circulation
* D – ___________ (neurological status)
* E – Expose/_________control
Secondary Assessment
* F – Full set of ______ signs/ Focused adjuncts/ Family Presence
* G – Give ______ (pharmacologic and non-pharmacologic)
* H – ________ and Head-to-toe assessment
* I – Inspect _________ surfaces
Primary Assessment
* A – Airway with simultaneous cervical spine protection
* B – Breathing
* C – Circulation
* D – Disability (neurological status)
* E – Expose/Environmental control
Secondary Assessment
* F – Full set of vital signs/ Focused adjuncts/ Family Presence
* G – Give comfort (pharmacologic and non-pharmacologic)
* H – History and Head-to-toe assessment
* I – Inspect posterior surfaces
93
Pediatric Airway
* Large ______
* ______ oral cavity
* Epiglottis is higher/bigger/floppy
* Trachea is ______
* Cricoid cartilage is narrowest portion of the airway
* Larynx is cephalad and more anterior → more difficult to visualize during intubation
* Large tongue
* Small oral cavity
* Epiglottis is higher/bigger/floppy
* Trachea is shorter
* Cricoid cartilage is narrowest portion of the airway
* Larynx is cephalad and more anterior → more difficult to visualize during intubation
94
Pediatric Breathing
* Upper and lower airways are considerably ______
* Preferential _____ breathers until 6 months old
* Nasal breathing doubles the resistance to air flow and increases WOB
* Swelling from trauma or infection narrowing large increases in airway resistance
* Upper and lower airways are considerably smaller
* Preferential nose breathers until 6 months old
* Nasal breathing doubles the resistance to air flow and increases WOB
* Swelling from trauma or infection narrowing large increases in airway resistance
95
* Child’s diaphragm has a _________ insertion
* Adult has a dome shaped/concave diaphragm
* Infants and small children breathe primarily with the diaphragm until age 2 – 3
* Child’s diaphragm has a horizontal insertion
* Adult has a dome shaped/concave diaphragm
* Infants and small children breathe primarily with the diaphragm until age 2 – 3
96
Pediatric Circulation
* ______ heart size
* Less contractile mass
* Decreased myocardial compliance
* Stroke volume is limited
* CO increased by increasing ____ rather than contractility
* When HR limits are reached, CO falls precipitously > shock
* Bradycardia followed by asystole is the most common pediatric arrhythmia
* Small heart size
* Less contractile mass
* Decreased myocardial compliance
* Stroke volume is limited
* CO increased by increasing HR rather than contractility
* When HR limits are reached, CO falls precipitously > shock
* Bradycardia followed by asystole is the most common pediatric arrhythmia
97
Pediatric Patterns of Injury; Toddlers (1 – 3 years) and Preschoolers (3 – 6 years)
* Motor vehicle traumas: both passenger and
pedestrian
* Back-over injuries
* Falls, poisonings, burns, and drowning
* Motor vehicle traumas: both passenger and
pedestrian
* Back-over injuries
* Falls, poisonings, burns, and drowning
98
Pediatric Patterns of Injury Infants (1mo – 1 year)
* Falls, choking, and strangulation
* Non-accidental injuries (__________)
Suspected Child Abuse and Neglect
SCAN Team
* Falls, choking, and strangulation
* Non-accidental injuries (child abuse)
Suspected Child Abuse and Neglect
SCAN Team
99
Non Accidental Trauma (NAT) Child Abuse
* Estimated ____% of children will experience some form
* ↑ Risk Children with “special needs” for example Cerebral Palsy and developmental delays (CPDD)
* ↑ Multiple births have increase risk, ie Twins,Triplets...
* Estimated 25% of children will experience some form
* ↑ Risk Children with “special needs” for example Cerebral Palsy and developmental delays (CPDD)
* ↑ Multiple births have increase risk, ie Twins,Triplets...
100
Nursing Assessment for NAT Common indicators:
* Inconsistent stories from parents and child
* Injuries non congruent with age and development (bruises on an infant)
* Injuries not correlated to reported cause
(severe head injury from fall from bed or changing table)
* Fractures of various stages of healing on a skeletal exam
* Retinal hemorrhages on ophthalmic exam
* Inconsistent stories from parents and child
* Injuries non congruent with age and development (bruises on an infant)
* Injuries not correlated to reported cause
(severe head injury from fall from bed or changing table)
* Fractures of various stages of healing on a skeletal exam
* Retinal hemorrhages on ophthalmic exam
101
House hold medications are MOST causes for Emergency Department visits.
* For any ingestion follow :
your ABCs –
* Airway
* Breathing
* Circulation
102
Burns:
* __ most common cause of death (After automobile accidents and firearms etc) in children < 15 years old
* Children younger the 5 years are at the highest risk of getting burned
* Children younger that 2 years have the highest risk of mortality
* 5th most common cause of death (After automobile accidents and firearms etc) in children < 15 years old
* Children younger the 5 years are at the highest risk of getting burned
* Children younger that 2 years have the highest risk of mortality
103
Anticipatory Guidance
* _______ are the most common cause of burns
* Water heater temperature CAN and should be set to less than 140 degrees (50 C) Recommended temp for bathing is 98 degrees
* Be aware of hot soups
* Adults drinking hot beverages can spill on child
* Cooking hot liquids on stove top
* SCALDs are the most common cause of burns
* Water heater temperature CAN and should be set to less than 140 degrees (50 C) Recommended temp for bathing is 98 degrees
* Be aware of hot soups
* Adults drinking hot beverages can spill on child
* Cooking hot liquids on stove top
104
Burns: Birth to 2 years of AGE
* Greater central body surface area
* Greater part of the body surface area is concentrated in the head and trunk
* More likely to have serious burns to head and trunk
* Greater ________________ proportionate to body size
* Less effective cardiovascular responses
* Burns of the face and chest – ASSESS Airway !
* Greater central body surface area
* Greater part of the body surface area is concentrated in the head and trunk
* More likely to have serious burns to head and trunk
* Greater fluid volume loss proportionate to body size
* Less effective cardiovascular responses
* Burns of the face and chest – ASSESS Airway !
105
Pediatric Burns Continued
* Can not use the rule of 9s to estimate % of Burns
* The __________________ is commonly used guideline for calculating fluid replacement and maintenance . And is referenced in the Pediatric Section in burns in the NCLEX review book.
* Other formulas
Lund-Browder
* Can not use the rule of 9s to estimate % of Burns
* The Parkland Formula is commonly used guideline for calculating fluid replacement and maintenance . And is referenced in the Pediatric Section in burns in the NCLEX review book.
* Other formulas
Lund-Browder
106
Burns- What to teach parents
* Flood the injured area immediately with _____ water for 10 to 15 minutes
* Once the burn has cooled - remove _________ from the injured area
* If material is sticking to the skin - don’t try to remove - needs to be done by a medical professional
* lf the burn or scald starts to hurt again – flood again with cool water
* Flood the injured area immediately with cool water for 10 to 15 minutes
* Once the burn has cooled - remove clothing from the injured area
* If material is sticking to the skin - don’t try to remove it – this needs to be done by a medical professional
* lf the burn or scald starts to hurt again – flood again with cool water
107
Burns- education cont.
* Don’t touch the injured area or burst any blisters – this can cause infection
* If possible remove rings and watches from the injured area as it may swell
* Loosely cover the burn or scald with non-fluffy material to stop infection – _________ is ideal but don’t wrap it around - just lay it loosely on top
* Don’t put any _______ - ointments - grease antiseptic spray or plasters on the injury
* Don’t touch the injured area or burst any blisters – this can cause infection
* If possible remove rings and watches from the injured area as it may swell
* Loosely cover the burn or scald with non-fluffy material to stop infection – cling film is ideal but don’t wrap it around - just lay it loosely on top
* Don’t put any creams - ointments - grease antiseptic spray or plasters on the injury
108
Pediatric Patterns of Injury - School-age (7 – 12 years)
* Largest risk of injury due to developing sense of __________
* Largest risk of injury while _______ riding
* Motor vehicle traumas: passenger – lap belt injuries
* Falls, poisonings, and drowning
* Number of suicides increasing annually
* Largest risk of injury due to developing sense of independence
* Largest risk of injury while bicycle riding
* Motor vehicle traumas: passenger – lap belt injuries
* Falls, poisonings, and drowning
* Number of suicides increasing annually
109
Child with the statistically highest risk of sustaining injury is the ___ year old schoolage _____ due to:
* Bravado
* Level of ______
* Perception that he “can take care of himself”
Child with the statistically highest risk of sustaining injury is the 8 year old schoolage male due to:
* Bravado
* Level of activity
* Perception that he “can take care of himself”
110
Pediatric Patterns of Injury - Teenagers (13 – 19 years)
* ______ – newly licensed drivers
* Incidence of injury increases with number of peers in the car
* ________ rate has increased during the last three decades
* MVC’s – newly licensed drivers
* Incidence of injury increases with number of peers in the car
* Suicide rate has increased during the last three decades
111
Four Common Errors in Pediatric Trauma Resuscitation
* Failure to open and maintain the _______ (with concurrent spinal stabilization and immobilization)
* Failure to provide adequate __________ and ventilation
* Failure to provide adequate ______ resuscitation (including children with brain injury)
* Failure to recognize and treat __________
* Failure to open and maintain the airway (with concurrent spinal stabilization and immobilization)
* Failure to provide adequate oxygenation and ventilation
* Failure to provide adequate fluid resuscitation (including children with brain injury)
* Failure to recognize and treat hemorrhage
112
Examples of Primary, Secondary, and Tertiary Injury Prevention Interventions
Primary Prevention: This includes strategies aimed at preventing injuries _______________. Examples include educating parents about safe sleep practices for infants and promoting the use of helmets for children while biking or skating.
Secondary Prevention: This focuses on ______________ and management of injuries to prevent ____________. Examples include screening children for developmental delays or evaluating for signs of abuse during medical visits.
Tertiary Prevention: This involves managing and _______________ to minimize _________ effects. An example is providing physical therapy to children after a serious injury to help them regain function.
Primary Prevention: This includes strategies aimed at preventing injuries before they occur. Examples include educating parents about safe sleep practices for infants and promoting the use of helmets for children while biking or skating.
Secondary Prevention: This focuses on early detection and management of injuries to prevent further harm. Examples include screening children for developmental delays or evaluating for signs of abuse during medical visits.
Tertiary Prevention: This involves managing and rehabilitating injuries to minimize long-term effects. An example is providing physical therapy to children after a serious injury to help them regain function.
113
Primary Prevention: This includes strategies aimed at preventing injuries before they occur.
Examples include educating parents about safe sleep practices for infants and promoting ______________ for children while biking or skating.
the use of helmets
114
Secondary Prevention: This focuses on early detection and management of injuries to prevent further harm.
Examples include screening children for___________________ or evaluating for signs of _______ during medical visits.
developmental delays
abuse
115
Tertiary Prevention: This involves managing and rehabilitating injuries to minimize long-term effects.
An example is providing ______________ to children after a serious injury to help them regain function.
physical therapy
116
the most common injury seen in children in the ED
1) Falls
Fire arm injuries, motor vehicle accidents
117
Proper Ways to Keep Firearms Safe in the Home:
Store firearms in a ________ cabinet or safe.
Keep ammunition stored __________ from the firearm.
Utilize trigger ______ and other safety devices to prevent unauthorized use.
___________ children about the dangers of firearms and ensure they understand not to touch them if found.
Store firearms in a locked cabinet or safe.
Keep ammunition stored separately from the firearm.
Utilize trigger locks and other safety devices to prevent unauthorized use.
Educate children about the dangers of firearms and ensure they understand not to touch them if found.
118
What kind of trauma is the number one death of children in the US?
Firearm injuries
then motor vehicle crashes
119
Prilosec : Omeprazole is a
Proton-pump inhibitor
120
Erikson---SOCIAL theory
Industry vs Inferiority
They like to do and accomplish
Example: Need to be Successful in Academic and Social Demands Children who are encouraged and commended by parents and teachers develop a feeling of competence (industry) and belief in their abilities. Those who receive little or no
encouragement from parents, teachers, or peers will doubt their ability to be successful and feel inferior
121
Moderate scoliosis
30 to 45 degrees - __________
bracing
122
[scoliosis] Bracing does not correct curve, but can :
slow or stop progression
123
Scoliosis bracing teaching
* Wear ___ hours per day
* Wear T-shirt under brace to decrease ________
* Check skin for signs of irritation
* Suggest clothing modifications to _________ brace
* Daily __________ to prevent atrophy of spinal and abdominal muscle
* Plan ways of improving __________
* Wear 23 hours per day
* Wear T-shirt under brace to decrease irritation
* Check skin for signs of irritation
* Suggest clothing modifications to camouflage brace
* Daily exercises to prevent atrophy of spinal and abdominal muscle
* Plan ways of improving self-concept
124
Narcotic Side effects
Potential Respiratory Depression
Sedation
Urinary Retention
Constipation
Nausea Vomitting
Puritis
Dizzyness
Dry Mouth
125
Nonpharmacological methods to relieve pain
126
Ketorolac (Toradol) is an IV NSAID
Effects on platelet adhesion and aggregation may _________________
prolong bleeding time.
127
Pyloric stenosis - post-op care
* Continue Maintenance IV ______
* Start small oral feedings w/ _________ replacement solution - 4 to 6 hours postop
* Position on _______ side in semi-Fowler position after eating
* _____ frequently
* ______ daily,
* Strict I & O
* Continue Maintenance IV fluids
* Start small oral feedings w/ electrolyte replacement solution - 4 to 6 hours postop
* Position on right side in semi-Fowler position after eating
* Burp frequently
* Weigh daily,
* Strict I & O
128
bowel perforation S&S
* ______
* Severe abdominal ______ and tenderness
* Abdomen ___________
* ________________
* Fever
* Severe abdominal pain and tenderness
* Abdomen distension
* Nausea and vomiting
129
What is NAT?
non accidental trauma
130
who is at risk for NAT?
* ↑ Risk Children with “special needs” for example Cerebral Palsy and developmental delays (CPDD)
* ↑ Multiple births have increase risk, ie Twins, Triplets...
131
__________ is surgery to cut out a layer of tissue called the fascia that lies deep under the skin
Fasciectomy is surgery to cut out a layer of tissue called the fascia that lies deep under the skin
131
COMPARTMENTAL SYNDROME
Progressive decrease in tissue perfusion resulting from ________________ from edema (swelling) or bleeding that presses on tissues and vessels. Causes compromised circulation. If not treated can result in permanent nerve and vascular damage and potential need for amputation.
increased pressure
131
NAT Common indicators:
* __________ stories from parents and child
* Injuries non congruent with age and development (________ on an infant)
* Injuries not correlated to reported cause (severe head injury from fall from bed or changing table)
* Fractures of ______________ of healing on a skeletal exam
* Retinal ___________ on ophthalmic exam
* Inconsistent stories from parents and child
* Injuries non congruent with age and development (bruises on an infant)
* Injuries not correlated to reported cause (severe head injury from fall from bed or changing table)
* Fractures of various stages of healing on a skeletal exam
* Retinal hemorrhages on ophthalmic exam
131
Pavlik harness Worn continuously for _________s until hip stable
2- 3 month
131
Pediatric burns- The Parkland Formula is commonly used guideline for
calculating _______________ and maintenance
fluid replacement
132
MANAGING THE CHILD WITH A CAST
* Plaster cast dries in 72 hours
* Keep uncovered while drying; avoid touching
* Turn cast every 2 hours while cast drying
Fiberglass cast dries in 30 min
* Diapering; petaling cast
* Check pulse and CSM of distal toes frequently
* Keep cast elevated, ice packs to reduce swelling
* Report if limb becomes painful, change color, cold, lose motion or sensation
132
Obesity: Management
Goal: do not attempt to lose weight, maintain weight so height can catch up
* __________- centered treatment
* Establish health eating habits _______
* Adult responsibility (to provide ________ foods in positive environment)
* Child responsibility (to eat)
* Authority and pressure to “eat right” are ________-productive; do not push a child to eat “good food” or forbid a child from eating “bad food.”
* Family - centered treatment
* Establish health eating habits early
* Adult responsibility (to provide healthful foods in positive environment)
* Child responsibility (to eat)
* Authority and pressure to “eat right” are counter-productive; do not push a child to eat “good food” or forbid a child from eating “bad food.”
132
Diagnosis of hip dysplasia
Infant
* Positive Ortolani and Barlow tests (.>2 months of age will not detect)
* Unequal folds of skin on buttock and thighs
* Limited abduction of affected hip
* Unequal leg lengths
Older child
* Limp on affected side
* Trendelenburg sign-pelvis dips when walking or standing to maintain balance
132
SKIN TRACTION FOR FRACTURES
Restores Tension to Surrounding Tissues
________ fracture
Decreases ______
Helps realign the ______
Usually applied in ED temporarily waiting surgery
Restores Tension to Surrounding Tissues
Stabilizes fracture
Decreases Pain
Helps realign the bone
Usually applied in ED temporarily waiting surgery
132
COMPLICATIONS OF FRACTURES
* Circulatory impairment
* Nerve compression
* Compartment syndrome
* Epiphyseal damage
* Non union or malunion of bone
* Osteomyelitis
* Pulmonary emboli
* Shock hypovolemia
132
A ___________________ is a surgical procedure for severe acid reflux (GERD).
Surgeon takes the upper part of the stomach and wraps it around the lower part of the esophagus, creating a tighter barrier to prevent stomach acid from flowing back up into the esophagus.
A Nissen fundoplication is a surgical procedure for severe acid reflux (GERD).
Surgeon takes the upper part of the stomach and wraps it around the lower part of the esophagus, creating a tighter barrier to prevent stomach acid from flowing back up into the esophagus.
133
Intussusception – complications
bowel obstruction
tissue damage/death
infection
shock
133
6-12 Y.o healthy lifestyle
Fruits, veggies, whole grains, lean meats, and fish
Increase ______, decrease juice, decrease cola, decrease processed food
Activity (exercise) ____ min/day
Limit screen time to ___ hours (quality) screen time/day
First permanent teeth come in about age 6
Brush teeth ___ / day
Traffic safety, water safety, _______ safety
Fruits, veggies, whole grains, lean meats, and fish
Increase water, decrease juice, decrease cola, decrease processed food
Activity (exercise) 60 min/day
Limit screen time to 2 hours (quality) screen time/day
First permanent teeth come in about age 6
Brush teeth 2x / day
Traffic safety, water safety, firearm safety
133
Hirschsprung’s-and post op care
pain management
watch for complications
monitor BM passing
134
Hospitalized School Age children
Be direct and straightforward: explain all _____________ is important
Contact with _______ is extremely important during hospitalization
Have toys/ activities in the hospital
>Take patient "out" for a _____ around the unit or wheel them around in those toy cars
Be direct and straightforward: explain all procedure is important
Contact with peers is extremely important during hospitalization
Have toys/ activities in the hospital
>Take patient "out" for a walk around the unit or wheel them around in those toy cars
135
How to rate pain for ages 4-7, 8+?
4-7 - wong baker faces
8+ - 0-10 scale
136
Most common types of child maltreatment:
neglect, physical abuse, sexual abuse, emotional abuse
neglect, physical abuse, sexual abuse, emotional abuse
137
Child maltreatment
Nurses are mandated __________ .
Failure to report:
$1000 and 6 months jail time
$5,000 and 1 year jail time if there was serious harm to the child
If atypical __________ is noticed:
<3 years: skeletal survey x-ray
<6 months (or head bruising): head CT
Abdominal bruising: abdominal CT
Extensive bruising: Check for organ damage with CBC, LFT, amylase, UA, PT, PTT, troponin
Nurses are mandated reporters.
Failure to report:
$1000 and 6 months jail time
$5,000 and 1 year jail time if there was serious harm to the child
If atypical bruising is noticed:
<3 years: skeletal survey x-ray
<6 months (or head bruising): head CT
Abdominal bruising: abdominal CT
Extensive bruising: Check for organ damage with CBC, LFT, amylase, UA, PT, PTT, troponin
138
Child Maltreatment: Risk factors
For the child survivor: ________ behaviors, ________ fragility, nonbiological relationship, prematurity, ________ needs (ex: Cerebral and developmental delays (CPDD))
In the environment: Unemployment, IPV, poverty, social isolation
For the child survivor: difficult behaviors, medical fragility, nonbiological relationship, prematurity, special needs (ex: Cerebral and developmental delays (CPDD))
In the environment: Unemployment, IPV, poverty, social isolation
139
Child Maltreatment: Risk factors
For the abuser: difficulty with showing concern and building relationships, critical and ______ with child for their injury, poor historian, increased risk multiple _______ (i.e. twins, triplets, etc)
For the abuser: difficulty with showing concern and building relationships, critical and angry with child for their injury, poor historian, increased risk multiple births (i.e. twins, triplets, etc)
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High suspicion of abuse if:
There is a _________ for getting medical advice
There is an _____________ stories among caretakers or between child and caretaker
There are other _____________ injuries not congruent with age and development or no correlated to reported cause
Fx of __________ stages of healing
There is ____________ behavior
There is a delay for getting medical advice
There is an inconsistent stories among caretakers or between child and caretaker
There are other unexplained injuries not congruent with age and development or no correlated to reported cause
Fx of various stages of healing
There is inappropriate behavior
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TEN-4: acroym for abuse
Bruising on Torso, Ears, Neck in a kid <4 years old, or
ANY bruising on a kid <4 months old
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Child maltreatment: Presentation by age
Infants: failure to thrive, shaken baby syndrome, skull fracture, head injury, tense fontanelle, retinal hemorrhages
Toddlers: fractures, bruises, burns, bite marks
Infants: failure to thrive, shaken baby syndrome, skull fracture, head injury, tense fontanelle, retinal hemorrhages
Toddlers: fractures, bruises, burns, bite marks
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Child maltreatment: Presentation by age
School age: low _________, fear to go home, depression, need to protect siblings, inappropriate clothing
Adolescents: promiscuity, STDs, bruises, fear of gym class, fear of physical contact
School age: low self-esteem, fear to go home, depression, need to protect siblings, inappropriate clothing
Adolescents: promiscuity, STDs, bruises, fear of gym class, fear of physical contact
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Presentation of Sex abuse: refusal _____ change in gym, running away, excessive sex knowledge, excessively protective adult
refusal top change in gym, running away, excessive sex knowledge, excessively protective adult
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Child maltreatment: Munchausen by proxy
Abuser makes it look like the child is _____ , either by causing real symptoms or making up fake symptoms.
Average victim age: ___ years old
Can cause lab results that don’t make sense with the symptoms reported
Often reported with 3 or more different medical issues, including apnea, anorexia, diarrhea, and/or seizures.
Abuser makes it look like the child is sick, either by causing real symptoms or making up fake symptoms.
Average victim age: 4 years old
Can cause lab results that don’t make sense with the symptoms reported
Often reported with 3 or more different medical issues, including apnea, anorexia, diarrhea, and/or seizures.
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Burns (0-2 y.o)
ASSESS:
Airway
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What is the parkland formula?\
Used for burns age 0-2
calculating replacement and maintenece fluids
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Nonpharmacological Pain Management
Infants: Music, pacifier, massage, kangaroo care, swaddling
Toddlers: Storybooks, blowing bubbles, pinwheels or feathers, simple cartoons/videos
School age: Video games, movies, relaxation breathing, guided imagery, music, books, iPad
Adolescent: Relaxation breathing, guided imagery, music, biofeedback
Infants: Music, pacifier, massage, kangaroo care, swaddling
Toddlers: Storybooks, blowing bubbles, pinwheels or feathers, simple cartoons/videos
School age: Video games, movies, relaxation breathing, guided imagery, music, books, iPad
Adolescent: Relaxation breathing, guided imagery, music, biofeedback
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Other nonpharmacological techniques:
Heat or cold
Elevation
TENS (transcutaneous electrical nerve stimulation)
Massage (if no injury present)
Acupuncture
Acupressure
Heat or cold
Elevation
TENS (transcutaneous electrical nerve stimulation)
Massage (if no injury present)
Acupuncture
Acupressure
150
PCA
-2 functions
Basal opioid (continuous): dose based on pt weight
PCA dose (intermittent): button can be ordered q 8-10 min initially
-Most common opioids
_____
_____
_____
-2 functions
Basal opioid (continuous): dose based on pt weight
PCA dose (intermittent): button can be ordered q 8-10 min initially
-Most common opioids
Morphine
Fentanyl
Dilaudid
151
PCA should be used by
Pt only
152
Fentanyl
Quicker onset but ________ lasting
shorter
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Narcotic SE:
Potential __________________
___________
_________ retention
Constipation
Nausea/vomiting
Pruritis
Dizziness
____ mouth
Potential respiratory depression
Sedation
Urinary retention
Constipation
Nausea/vomiting
Pruritis
Dizziness
Dry mouth
154
Narcan (Naloxone)
Opioid antagonist = reverses effects of _______
May require repeating
Adjust dose if on high dose of opioid or history of chronic opioid use
Opioid antagonist = reverses effects of opioid
May require repeating
Adjust dose if on high dose of opioid or history of chronic opioid use
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Ketorolac (Toradol)
Ibuprofen (Motrin)
Side Effects:
________ dysfunction
Risk of __________
________ ulceration
______ toxicity
Platelet dysfunction
Risk of hemorrhage
Gastric ulceration
Renal toxicity
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Ketorolac (Toradol) - IV NSAID
Use for < __ days
Monitor _____ function and platelets before admin
Effects on platelet adhesion and aggregation may prolong ________ time
0.5-1.0 mg/kg/dose q 6-8 hr
Max dose: 30 mg
Max: 40 mg/kg/24 hrs
Use for < 5 days
Monitor renal function and platelets before admin
Effects on platelet adhesion and aggregation may prolong bleeding time
0.5-1.0 mg/kg/dose q 6-8 hr
Max dose: 30 mg
Max: 40 mg/kg/24 hrs
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Musculoskeletal: Hip dysplasia
Abnormal development of the ________ head in the acetabulum
Wide range of abnormal development of the hip = hip _________
Tx required d/t possibility of a limp, constant pain, impaired mobility later in life, early arthritis
Risk factors: female, family hx, first born, joint laxity, breach birth, increased fetal size
Ethnicities: Increased incidence in Navajo and Canadian Natives, decreased incidence in Africans and far east
Abnormal development of the femoral head in the acetabulum
Wide range of abnormal development of the hip = hip instability
Tx required d/t possibility of a limp, constant pain, impaired mobility later in life, early arthritis
Risk factors: female, family hx, first born, joint laxity, breach birth, increased fetal size
Ethnicities: Increased incidence in Navajo and Canadian Natives, decreased incidence in Africans and far east
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Hip Dysplasia - Assessment
Infant: Positive Ortolani and Barlow (>___ mo will not detect)
2
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Hip Dysplasia S&S
Infant: unequal folds of skin on buttock and thighs, limited abduction of affected hip, unequal leg lengths
Older child: limp when walking, Trendelenberg sign (pelvis dips when walking/standing to maintain balance)
Infant: unequal folds of skin on buttock and thighs, limited abduction of affected hip, unequal leg lengths
Older child: limp when walking, Trendelenberg sign (pelvis dips when walking/standing to maintain balance)
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Hip Dysplasia Management
0-6 months: _______ harness for 3-5 mo, adjust every 1-2 weeks
6-18 months: ________ traction for 3 wks, hip spica cast for 3 mo, reduction, surgery
18+ months: _________ reduction (best if <4 yrs), reconstruction, post op casting
0-6 months: Pavlik harness for 3-5 mo, adjust every 1-2 weeks
6-18 months: Bryant traction for 3 wks, hip spica cast for 3 mo, reduction, surgery
18+ months: Operative reduction (best if <4 yrs), reconstruction, post op casting
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Pavlik harness
Worn continuously for ___ mo until hip stable
Straps checked q 1-2 wk for adjustment
Improper application can lead to femoral nerve palsy & avascular _________ of the femoral head
Worn continuously for 2-3 mo until hip stable
Straps checked q 1-2 wk for adjustment
Improper application can lead to femoral nerve palsy & avascular necrosis of the femoral head
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Hip dysplasia - Pavlik Harness
Harness worn ____ except for bath
24hrs
163
Managing a Child With a Cast
Plaster cast dries in ___ hours
Keep uncovered while drying; avoid touching
Turn cast q 2 hr while drying
Fiberglass cast dries in ____ min
Diapering --> petaling cast
Check pulse and CSM (circulation/sensation/motor function) of distal toes frequently
Keep cast elevated; ice packs to reduce swelling
Report if limb becomes painful, change color, cold, lose motion/sensation, increasing pain on passive extension of digits
Plaster cast dries in 72 hours
Keep uncovered while drying; avoid touching
Turn cast q 2 hr while drying
Fiberglass cast dries in 30 min
Diapering --> petaling cast
Check pulse and CSM (circulation/sensation/motor function) of distal toes frequently
Keep cast elevated; ice packs to reduce swelling
Report if limb becomes painful, change color, cold, lose motion/sensation, increasing pain on passive extension of digits
164
Common in children – 15% of all injuries in children are:
fractures
165
Epiphyseal Fractures
Epiphyseal plate: ________ point of long bones
Normally heals ________ and completely
Risk of damage to growth plate
______ identification is critical to minimize growth problems/deformities
Epiphyseal Fractures
Epiphyseal plate: weakest point of long bones
Normally heals quickly and completely
Risk of damage to growth plate
Early identification is critical to minimize growth problems/deformities
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Musculoskeletal: Fractures
Common types: _________ (most common), spiral, communicated, transverse, vertebral compression
Simple/closed vs open/compound
greenstick
167
Fracture Complications are associated with ___________ and underlying organ tissue damage
inflammation
168
Fractures Healing time:
Neonate: 2-3 weeks
Early childhood: 4 weeks
Later childhood: 6-8 weeks
Adolescents: 8-12 weeks
Adults: 10-16 weeks
Neonate: 2-3 weeks
Early childhood: 4 weeks
Later childhood: 6-8 weeks
Adolescents: 8-12 weeks
Adults: 10-16 weeks
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Complications of Fractures
Circulatory impairment
Nerve compression
Compartment syndrome
Epiphyseal damage
Non-union or malunion of bone
Osteomyelitis
Pulmonary emboli
Shock hypovolemia
Circulatory impairment
Nerve compression
Compartment syndrome
Epiphyseal damage
Non-union or malunion of bone
Osteomyelitis
Pulmonary emboli
Shock hypovolemia
170
Compartment Syndrome
Painful buildup of _________ around muscle; ER
Occurs after severe injuries/surgery complication (acute)
Occurs over time when _________ too hard/often
Painful buildup of pressure around muscle; ER
Occurs after severe injuries/surgery complication (acute)
Occurs over time when exercise too hard/often
171
Scoliosis - Boston brace:
Wear ___ hr/day
Wear t-shirt under brace to decrease irritation
Check skin for signs of irritation
Suggest clothing mods to camouflage brace
Daily exercises to prevent _________ of spinal and abdominal muscle
Plan ways of improving self-concept
Wear 23 hr/day
Wear t-shirt under brace to decrease irritation
Check skin for signs of irritation
Suggest clothing mods to camouflage brace
Daily exercises to prevent atrophyof spinal and abdominal muscle
Plan ways of improving self-concept
172
Musculoskeletal: Soft Tissue Injuries Management:
Elevation
RICE
Rest
Ice
Compression
Elevation
173
Musculoskeletal: Slipped Capital Femoral Epiphysis (SCF)
Displacement of proximal femoral epiphysis in posterior and inferior direction
Most common before or during _______________ and onset of puberty
Increased incidence in: _____ and _______ children
Symptoms: weakness in leg, limping, lack of hip rotation
Treatment: surgery for pinning
Displacement of proximal femoral epiphysis in posterior and inferior direction
Most common before or during accelerated growth and onset of puberty
Increased incidence in: males and obese children
Symptoms: weakness in leg, limping, lack of hip rotation
Treatment: surgery for pinning
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Restricted Blood Flow to Extremity
Perform neurovascular checks
5 P's: _________________________________________________________________________________________________________
Check for Swelling
Monitor pain
Pain, pallor, pulselessness (Circulatory), paresthesia (Sensory), paralysis (motor) = CSM Assessment
175
Pyloric stenosis
Pyloric sphincter hypertrophies and :
closes the canal
176
Pyloric stenosis Assessment:
Non-bilious, non-bloody (NBNB) projectile ___________
Olive-shaped _______ in upper right quadrant (the hypertrophied pyloric sphincter)
Hunger, weight loss, dehydration with ↓K and ↓Na
Metabolic alkalosis
Visible _________ waves
Non-bilious, non-bloody (NBNB) projectile vomiting
Olive-shaped mass in upper right quadrant (the hypertrophied pyloric sphincter)
Hunger, weight loss, dehydration with ↓K and ↓Na
Metabolic alkalosis
Visible peristalsis waves
176
Pyloric stenosis Treatment: ____________ (surgery to open the sphincter)
Position on right side post op
Give electrolyte solution (because they will still be N/V)
pyloromyotomy
177
Hirschsprung Disease (Congenital Aganglionic ___________)
Megacolon
178
Hirschsprung Disease
Missing parasympathetic ganglion cells in distal colon/rectum, leading to no peristalsis and fecal ____________
Common with ______________
Assessment:
Newborn without meconium in first ________
Ribbon-like stool in older child
Distended abdomen
Diarrhea
Missing parasympathetic ganglion cells in distal colon/rectum, leading to no peristalsis and fecal accumulation
Common with Down's Syndrome
Assessment:
Newborn without meconium in first 24 hours
Ribbon-like stool in older child
Distended abdomen
Diarrhea
179
Hirschsprung Disease Complication: ___________ (inflammation of the digestive tract)
Enterocolitis
180
GERD medications
Antacids
_______ relief; longterm not rec'd
Decreases acid effect
Proton Pump Inhibitors (PPI)
Rec'd as ______ tx
Decreases _________ production
Antacids
Temp relief; longterm not rec'd
Decreases acid effect
Proton Pump Inhibitors (PPI)
Rec'd as 1st line tx
Decreases gastric acid production
181
Kidney function is decreased until
2 years old
182
Inguinal hernia
Congenital __________ of abdominal content into the inguinal canal, noticeable at 2-3 months
You can feel a palpable bulb when the child bears down (valsalva maneuver)
If the protruding abdominal content is strangulated (not getting blood supply), it is an emergency!
S/S: irritability, anorexia, tenderness, abdominal distention
Management: _________
Congenital protrusion of abdominal content into the inguinal canal, noticeable at 2-3 months
You can feel a palpable bulb when the child bears down (valsalva maneuver)
If the protruding abdominal content is strangulated (not getting blood supply), it is an emergency!
S/S: irritability, anorexia, tenderness, abdominal distention
Management: surgery
