NURS 232 PEDS EXAM II LATEST 2023/2024 EXAM 200 QUESTIONS AND 100% CORRECT VERIFIED ANSWER, Exams of Nursing

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NURS 232 PEDS EXAM II LATEST 2023/2024 EXAM 200 QUESTIONS AND 100% CORRECT VERIFIED ANSWERS WITH RATIONALES (GRADED A) A child's asthma would be considered intermittent and controlled if: a) their normal activity is somewhat limited by their asthma b) they have daily nighttime awakening w/ asthma symptoms c) they have daily symptoms of their asthma d) they have 0-1 exacerbation per year d) they have 0-1 exacerbation per year . *refer to Table 20-5 Classification of Asthma *a) moderate persistent; b) severe persistent; c) moderate persistent A child's asthma would be considered in the yellow zone when: a) PEFR is <50% of their personal best and they have symptoms b) PEFR is 50-80% of their personal best and they have symptoms c) PEFR is 50-80% of their personal best and they do not have symptoms d) PEFR is 80-100% of their personal best and they do not have symptoms b) PEFR is 50-80% of their personal best and they have symptoms *developing breathing problems *refer to "Families Want to Know- Using Expiratory Peak Flow Meter" *a) is red zone; d) is green zone Apnea in an infant is defined as a pause in or absence of respiration's for more than: a) 10 secs b) 20 secs c) 45 sec d) 1 min b) 20 secs **normal if <20 sec Which of the following is an effective anti-inflammatory meds for asthma control? a) Beta2 adrenergic agonists b) Inhaled corticosteroids c) Leukotriene receptor antagonists d) Mast cell stabilizer b) Inhaled corticosteroids (ex: fluticasone) *a) quick relief bronchodilator; c)both bronchodilator and anti-inflammatory d) anti-inflammatory for allergen exposure *refer to "Medications Used to Treat: Asthma" The school nurse goes to the soccer field when a 7 yr old student w/ asthma is coughing, wheezing, and having trouble catching her breath. The nurse should give which med? a) albuterol b) fluticasone [flovent] c) prednisone d) montelukast [singular] a) albuterol *short acting beta2 agonist; quick relief med *b=inhaled corticosteroid, c= corticosteroid, d=leukotriene receptor agonist Respiratory failure occurs when: a) retractions and an increased RR b)body can no longer maintain effective gas exchange c) periodic pause in respiration up to 20 secs b) body can no longer maintain effective gas exchange Which nursing interventions are important for an 18 mos old w/ moderate respiratory distress? a) elevate HOB b) identify parents and state own name c) state full name and phone number d) identify current month but not the date b) identify parents and state own name *use Table 27-5 "GCS for infants and children" or Table 27-2 "AVPU" *Alert, Verbal, Pain response, Unresponsive The parent of a 4 month old w/ cystic fibrosis asks the nurse what time to begin the child's 1st chest physiotherapy (CPT) each day. Which is the nurse's best response? a) "30 mins before breakfast" b) "after deep suctioning the child each morning" c) "30 mins after breakfast" d) "only when the child has congestion or coughing" a) "30 mins before breakfast" *do it before meals because may make them vomit; will not deep suction; will do this several times a day A child recently diagnosed w/ epilepsy is being evaiulated for anticonvulsant med therapy. The child will likely be placed on which type of regimen? a) 2-3 oral anticonvulants meds so that dosing can be low and side effects minimized b) 1 oral anticonvulants med to observe effectiveness and minimize side effects c) 1 rectal gel to be administered in the event of a seizure d) combo of oral and IV meds to ensure compliance b) 1 oral anticonvulants med to observe effectiveness and minimize side effects *if not effective switch to another med; try not to use more than 1 at a time What are risk factors for ceberal palsy? (select all apply) a) low birth weight b) birth hypoxia c) genetics d) increased maternal age e) neonatal infections a) low birth weight b) birth hypoxia e) neonatal infections *neonatal sepsis, hyperbilirubinemia, very premature, CNS infection, head trauma, and injury at birth from trauma or asphyxia *nonprogressive motor and posture dysfunction; occurs from insult in prenatal, perinatal, or postnatal period up to 2 yrs of age *majority from intrauterine insults, structural abnormalities of CNS, but also insufficient nutrients or O2 An 8 yr old w/ hydrocephalus has ventriculoperitoneal shunt. What s/s would indicate shunt malfunction? (select all apply) a) increased head circumference b)fever c) headache d) blurred vision e) RR of 20 b)fever c) headache d) blurred vision *looking for s/s of ICP refer to Table 27-4 "Signs of ICP" for other signs *headache, visual disturbance, diplopia, N/V, dizziness/vertigo, slight change VS, pupils not reactive or equal, sunsetting eyes, slight change LOC *a) is indicated for infants and e) is normal What are the normal RR for each of the following ages: -Newborn -1 yrs -3 yrs -6 yrs -10 yrs -17 yrs -Newborn: [30-55] -1 yrs: [25-40] -3 yrs: [20-30] -6 yrs: [16-22] -10 yrs: [16-20] -17 yrs: [12-20] What are the normal HR ranges for the following ages: -newborn -infant to 2 yrs -2 to 6 yrs -6 to 10 yrs -10 to 16 yrs -newborn HR is: [100-170] -infant to 2 yrs: [80-130] -2 to 6 yrs: [70-120] -6 to 10 yrs: [70-110] -10 to 16 yrs: [60-100] Why is early identification of autism important? a) parents of autistic children need support b) early intervention fosters better outcomes c) prevention of subsequent pregnancies is essential d) cure is possible only if diagnosed by 18 mos b) early intervention fosters better outcomes A teen begins therapy w/ methylphenidate (Ritalin). The nurse correctly counsels the pt and her pratens that: a) report any strange, uncontrollable facial movements, such as grimacing,as this is a possible side effect b) "don't drive as this med may make you sleepy" b) seizures c) hydrocephalus d) feeding difficulties e) accelerated developmental milestones a) spasticity (most common) b) seizures d) feeding difficulties *also abnormal muscle tone, lack of coordination, motor impairment, delayed dev milestones, maybe intellectual disabilities, vision/hearing impairments, speech/language impairments *ataxia, athetosis, dystonia less common A child presents to ER following febrile seizure. Appropriate treatment would include all of the following except: a) administer antiepileptic drug b) adminster antipyretic drug c) careful assessment of neuro status d) obtaining diagnositc labs, such as CBC and cultures a) administer antiepileptic drug *occurs 1 time during illness and last usually short duration so dont treat w/ AED; may occur in next illness *can give tylenol or motrin (if >6 mos) to lower temp A child receiving albuterol, 2 puffs every 3 hrs, for asthma exacerbation is a risk for developing which adverse effects? a) tachycardia, insomnia, and restlessness b) constipation, rash, and blurred vision c) bradypnea, leathargy, and tinnitus d) increased appetite, increased risk for super infection, and gum hyperplasia a) tachycardia, insomnia, and restlessness Cystic fibrosis is genetically transferred as which type of trait? a) autosomal dominant b) sex-linked c) multifactorial d) autosomal recessive d) autosomal recessive A mother of a 2 month old infant asks the nurse when she should introduce solid foods into her infants diet. Which of the following responses is most appropriate? a) "infants should only be given breast milk until they are 1 yr old" b) "you may feed your baby cereal now if he seems to be hungry after he eats" c) "you may feed your baby rice cereal beginning at 4 mos" d) "infants can be given yellow veggies when they are 4 mos old" c) "you may feed your baby rice cereal beginning at 4 mos" *introduce foods like rive or grain cereal by 4-6 mos, then veggies and fruit by 6-8 mos Which of the following findings would the nurse expect to see in an adolescent female who has been diagnosed w/ anorexia nervosa? (select all apply) a) lengthy and vigorous exercise b) decreased muscle tone c) strong, supportive family d) hypoglycemia a) lengthy and vigorous exercise b) decreased muscle tone d) hypoglycemia *refer to Table 14-7 "Diagnositic Criteria for Anorexia nervosa" *significant low body weight, fear of gaining weight, disturbed body image, restricting food A child w/ difficulty breathing and a "barking cough" is displaying signs associated w/ which condition? a) cystic fibrosis b) asthma c) epiglottitis d) croup d) croup *syndrome of upper airway infections; s/s of stridor, barking cough, hoarseness *experienced in all 4 types of croup like acute spasmodic laryngitis, laryngotracheobronchitis, tracheitis, and epiglotittis Which instruction about preventing SIDS should a nurse include when teaching the parents of an infant? a) position the infant on his stomach to sleep b) position the infant in an infant seat to sleep c) position the infant on his back to sleep d) position the infant in a side-lying position to sleep c) position the infant on his back to sleep *back to sleep campaign A nurse is assessing the lung sounds of a child w/ asthma. Which sounds is the nurse most likely to hear? a) vesicular sound b) wheezing c) crackles d) stridor b) wheezing *see tripod position, coughing, wheezing *may have absent sounds - look at whole picture b/c may be in distress and airway closed Which nursing intervention is appropriate when providing care for a client after a tonsillectomy? a) keep head midline b) suction the client every hour c) offer the child fruit punch to drink d) provide heat for comfort What AED: -used for partial and generalized seizures -can cause photosensitivity, skin rashes, SJS, blurred vision, dizziness *notify HC provider is skin rash b/c SJS -monitor dizziness, lack of coordination, drowsiness, depression if used w/ valproic acid Lamotrigine (Lamictal) What AED: -larger therapeutic range -neuro effects like sedation and nystagmus -bone marrow suppression *monitor blood counts like RBC, WBC, Platelets -skin rashes -photosensitivity -give w/ food to enhance absorption; not grapefruit juice Carbamazepine (Tegretol) What AED: -narrow therapeutic range (10-20) -neuro effects like sedation *toxic levels more sedation, nystagmus, ataxia *monitor VS for respiratory depressoin -gingival hyperplasia (overgrowth of gums) *frequent dental care -GI upset -skin rash -intake vitamin D, folic acid, and Ca+ -urine may be pink, red, or brown Phenytoin (Dilantin) What 3 traditional drugs are: - used for partial and generalized seiizures -reduce nerves' ability to be stimulated and suppress transmission -many, many drug interaction -CNS depressant effects 1) phenytoin (Dilantin) 2) Carbamazapine (Tegretol) 3) Valproic Avid (Depakote) What AED: -may crush tablets and mix w/ food or fluid -provide vitamin D and folic acid if long term use -tolerance to sedation w/ continued use -give vitmin k to mother 1 month before and during delivery, then immediately to newborn -don't stop abruptly, taper dose Phenobarbital What AED: -generally well tolerated -GI effects *give w/ food to decrease GI irritation -rare lethal hepatotoxicity *monitor liver values, platelet count, bleeding times -teratogenic effects; contraception Valproic acid (Depakote) What med is indicated for use w/ absence seizures? It may cause inital drowsiness Ethosuximade (Zarontin) What other meds might be used to treat seizures other than AED's? *used for status epilepticus Diazepam (Valium) or Lorazepam (Ativan) *watch for sedation and decreased LOC What med is a used for status epilepticus seizure disorder: -can be given IV or rectally -CNS depressant -short acting -paradoxical reactions may occur -respiratoy depression, hypotension, tachycardia and phlebitis w/ IV *caustic on vein! monitor site; only place in good vein; push very slowly; entry site closet to child's body Diazepam (Valium) What med is a used for status epilepticus seizure disorder: -can be given IV or rectally -anxiolytic, anticonvulsant, antiemetic, and sedative -fast acting -may be less respiratory depression than diazepam (valium) -caution in neonate b/c preservative Lorazepam (Ativan) What is a late s/s with increased ICP described as: -increased systolic BP, wide pulse pressure, diastolic same or decreased -bradycardia -irregular respirations Cushing's triad What are these s/s of: -significant decrease in LOC -seizures -fixed and dilated pupils -papilledema (swelling behind eyes) -cushing's triad (increased systolic BP, bradycardia, irregular respirations) Late s/s of increased ICP What are these s/s of: -headache -visual disturbances -increased risk w/ parents: poverty, depression, substance abuse, intellectual disability, psychosis, or socially or emotionally isolated -preterm and small for gestational age at risk -aka aviodant/restrictive food intake disorder failure to thrive *parents may not respond to hunger cues, infant is irritable, not soothed, no clear hunger cues, or parental neglect Which infants or young children are at risk for avoidant/restrictive food intake disorder aka failure to thrive? 1) Parents w/: -poverty -depression -substance abuse -intellectual disability -psychosis -socially and emotionally isolated 2) infants that are preterm of SGA What are clinical manifestations of child w/ avoidant/restrictive food intake disorder aka failure to thrive? -weight below 5 percentile -may refuse food -erratic sleep patterns -irritable -developmental delays What is the treatment for a child w/ avoidant/restrictive food intake disorder aka failure to thrive? -rule out other disorders -hospitalize to establish eating and sleeping patterns -assist parents in developing routines and understand cues What term is a feeding disorder of infants characterized by paroxysmal abd pain and severe crying that generally lasts at least 3 hrs at least 3 days a week *infant cries loudly and continuously for several hours, face flushed, abd distended and tense, draws up legs, clenches hands, same time each day, late afternoon or early evening; may stop when exhausted or pass flatus or stool Colic *may be from feeding too rapidly and swalloning large amount of air What is the term for cessation of respiration lasting longer than 20 seconds? Apnea What is the term for lower than normal amounts of O2 in blood? tisses? Hypoxemia; hypoxia What is the term for spasmodic vibrations of the larynx, which creates sudden, violent, unpredictable, involuntary contraction of airway muscles? Laryngospasm What is the term for a prolonged continuous seizure or or intermittent seizures for 15 minutes *look at clinical signs of EEG Status epilepticus *treat w/ diazepam (valium) or lorazepam (ativan) What is an abnormal, high-pitched, crow-like respiratory sounds caused when air moves through narrowed larynx or trachea? stridor What is the term of a visible drawing in of the skin of the neck and chest? *occurs on inspiration in infants and young children in respiratory distress retractions What is the term for an effort the child makes to widen the airway by widening the nares w/ breathing *sign of respiratory distress nasal flaring What is the term for sporadic episodes of apnea, not associated w/ cyanosis, that last for about 10 seconds *commonly occurs in preterm infants periodic breathing What is the term when a child will only eat 1 food time meal after meal? *fear of malnutrition food jag *common for preschoolers What med for asthma: -inhaled or nebulizer SABA -quick relief -bronchodilator and mucous clearing -drug of choice acute therapy and prevent exercise induced bronchospasm *use before inhaled steroid, wait 15 mins to give inhaled steroid *wait 1-2 mins between puffs *hold breath 10 secs after inspiring then rinse mouth and avoid swallowing *use w/ spacer Albuterol *refer to "Meds Used to Treat Asthma", p. 499 *SABA What meds for asthma: -oral corticosteroid -decrease airway inflammation, secretion, and obstruction; bronchodilator -for acute episodes -short term therapy until 80% peak expiratory flow or symptoms resolve *give w/ food to reduce GI irritation *early in morning to mimic normal peak corticosteroid blood level -can cause long term effects like decreased growth, unstable BS, immunosuppression What should be provided for pts w/ cystic fibrosis each time they eat? Pancreatic enzymes *whenever food is ingested What 4 "meds" will be used for CF? -dornase -ivacaftor -vitamins A,D,E,K in water soluble form -pancreatic enzymes What cystic fibrosis med: -aerosol -loosens and things pulmonary secretions to reduce exacerbations *keep refrigerated until placed in nebulizer *monitor improvement in dyspnea and mucous clearance dornase *refer to "Meds used to treat CF" p. 509 What cystic fibrosis med: -oral -improve salt and water absoprion and secretion in tisssues *monitor hepatic enzymes; hold if significantly elevated *administer w/ high fat foods *NO grapefruit juice or seville oranges Ivacaftor *refer to "Meds used to treat CF" p. 509 What cystic fibrosis med: -oral -assists digestion of nutrients decreasing fat and bulk *give w/ each meal and snacks Pancreatic enzymes *refer to "Meds used to treat CF", p. 509 What cystic fibrosis med: -oral -supplement vitamins not produced -prescribed in non-fat soluble form to promote absorption *give 2x daily Vitamins A, D, E, K *refer to "Meds used to treat CF" p. 509 What are the 2 different nutrition epidemics does the US currently have? 1) hunger/food insecutiry (r/t economic issues) 2) obesity (r/t sedentary lifestyles, poor food choices, nutritious food choices more costly) When should the parents introduce solid foods to their child? 4-6 mos *rice or grain cereal When should the parents introduce cow's milk to their child? 1 year *starting w/ whole milk until 2 yrs old (then can have 2%) What supplements may be needed for infants and young children? -fluoride if water doesn't contain enough -iron if breastfeeding and not enough iron from eating foods by 6 mos What type of formula should infants have if they are bottle feeding? iron fortified formula What foods should be avoided during infancy? -carrots, beets, squash, beans, and spinach (6 mos) -cow's milk & honey (1 yr)--- GI distress -eggs, strawberries, wheat, corn, and fish (2-3 yrs)---allergies -sugar, salt, and spices---GI distress -test well water for nitrates (<10) What food should be avoided for toddlers? -unpasteurized juice ---pathogens When should a child have whole milk? 2% milk? Whole = 1-2 yrs 2% = after 2 yrs What nutritional education is important for infant? -8 to 12 feedings/day -rice or single grain ceral = 4-6 mos -veggies and fruit = 6-8 mos -meats = 8-10 mos -honey = 1 yr -cow's milk = 1 yr -eggs, strawberries, wheat, corn, fish = 2-3 yrs -avoid sugar, salt, and spices b/c GI distress -introduce 1 new food q 3-4 days = assess for allergies -don't put to bed w/ bottle -make sit at table to eat; no playing -iron fortified formula = 1 st yr -iron supplement if no iron w/ foods and breastfeeding by 6 mos -dont feed when sleepy b/c dental caries -wipe teeth when erupr = 6 mos -1st dental visit = 1 yr If getting enough food intake and nutrients, when should the infants weight double? triple? 6 mos; 12 mos -hypothermia, cold intolerance -dry skin, brittle hair and nails -lanugo (thin fine hair) -fluid and electrolyte imbalances -constipation, abd discomfort, bloating -osteoporosis, decrease bone density, fractures *refer to Table 14-7 "diagnostic criteria for Anorexia Nervosa" What describes an eating disorder w/ binge and purge eating? What are some clinical manifestations and how is it accomplished? *think about age of onset, weight, psychological, PA Bulimia Nervosa -average age onset =20 yrs; adolescent and young adult females -cycles up to 8+ a day -purge w/ laxative abuse, vomiting, diuretic abuse, rigorous exercise -normal to slightly above/below weight -easily concealed b/c not significant weight change -tooth erosion, esophageal damage, GI concerns -self deprecation thought, depression, low impulse control -unsuccessful dieting; overweight in childhood *refer to Table 14-8 "diagnostic criteria for Bulimia Nervosa" When should we start to introduce finger foods to an infant? 8-10 mos when have pincer grasp What might be the cause for eating disorders? -unclear -psychologic component -pursuit of thinness -distorted body image -media impact -familial influence -feeling of control How are eating disorders diagnosed? ex: anorexia vs bulimia *refer to Tables 14-7 and 14-8 -based on psychologic and behavioral criteria -Anorexia: 1) intake restriction =low body weight 2) intense fear of gaining weight 3) disturbed body image -Bulimia: 1) binge eating 2) inappropriate compensatory behavior to prevent weight gain like vomiting, laxative misuse, diuretics, fasting, or excessive exercise 3) binge and purge at least 1x/week for 3 months What therapeutic management might be employed for eating disorders like anorexia or bulimia? -hospitilization -intense monitoring of weight - therapy -psychotherapy -antidepressants -correct electrolyte and fluid imbalances What are the 4 major goals for management of eating disorders like anorexia or bulimia? 1) healthy weight 2) healthy eating patterns 3) resolve disturbed pattern of family interactions 4) individual psychotherapy What are the anatomical and physiological differences in EENT for infants? -decreased visual acuity -see best at arm length (8 inches) -difficult to discriminate colors -cry w/out tears until 6 weeks -uncoordinated rectus muscles -optic nerve less mylinated -can't accommodate well -binocularity not until 6 mos -eustachian tube shorter, wider, and more horizontal -more prone to middle ear infections (otitis media) -primarily nose breathers until 6 mos Why is it important to make sure that the nasal passage of an infant is clear before eating? *use NS and bulb syringe to clear Primarily nose breathers until 6 mos *If nasal passage occluded from inflammation or mucous, difficult to suck and feed Why are infants and young children more prone to middle ear infections (otitis media)? shorter, wider, and more horizontal Eustachian tube *opening of eustachian tube during sucking and yawning What is one of the most prevalent diseases of early childhood? What is it most frequently caused by? -Otitis media; middle ear infection -by viral infection and short eustachian tubes What increases the likelihood for otitis media/ middle ear infections? -<2 yrs old -pre-school boys -smoker household -many members of household or daycare -pacifier for several hours What should be taught to parents to decrease risk of otitis media/ middle ear infection? What is it called when a newborn gets conjunctivitis in 1st 30 days of life? What can cause it to occur? *aka pink eye Opthalmia neonatorium -birth canal -blocked tear duct -prophylactic eye ointments for clamidia/gonorrhea What are the treatments for conjunctivitis? *aka pink eye -culture -topical antibiotics -warm compress -comfort measures What can cause retinopathy of prematurity= when they developing retinal capillaries are damaged? -prolonged O2 -apnea -hypoxia Who is most likely to experience retinopathy of prematuriy and when does it usually develop? -usually w/ premature infants; most common if born b/4 28 weeks -develops around 4-6 weeks after birth What is the progression of retinopathy of prematurity linked to? -low birth weight -greater prematurity -duration of O2 therapy What can prematurity of retinopathy cause? -decreased vision -blindess -retinal detachment *may experience healing or permanent eye damage and blindness What are s/s of conjunctivitis? -increased tearing/ discharge -wateriness -tearing of eyes -purulent drainage -crustiness esp. when waking -dry crustys around edges of eye -red eye -rub b/c itchy What can be done to detect or treat retinopathy in prematurity by repairing damaged vessels? -frequent eye exams if premature -laser therapy -cryotherapy What are respiratory anatomical and physiological differences in children -respiratory tract not fully developed at birth; continues to grow until 12 yrs old -airway shorter and narrower; organisms move down much more quickly until 8 yrs old -greater airway resistance & risk for obstruction b/c smaller airway -angle of right bronchus at bifurcation more acute -trachea cartilage more flexible -less number and maturity of alveoli -bronchi and bronchioles lined w/ smooth muscle=harder to work -diaphragm breathers b/c immature intercostal muscles until 6 yrs -ribs primarily cartilage so retractions during distress -infants nose breathers until 6 mos -consume more O2 r/t higher metabolic rate -fewer glycogen reserves = tire more easily if distress What are the 3 levels of respiratory dysfunction? 1) respiratory distress 2) respiratory failure 3) respiratory arrest *refer to Table 20-2 "Clinical manifestations of respiratory failure and imminent arrest" What are INITIAL clinical manifestations of respiratory failure leading to imminent respiratory arrest? *O2 deficit and airway blockage; behavior and VS compensation, and beginning hypoxia -restlessness -tachypnea -tachycardia -diaphoresis *refer to Table 20-2 "Clinical manifestations of respiratory failure and imminent arrest" What are EARLY DECOMPENSATION clinical manifestations of respiratory failure leading to imminent respiratory arrest? *use accessory muscle to assist O2 intake; hypoxia persists and waist more O2 than receive -nasal flaring -retractions -grunting -wheezing -anxiety -irritability -mood changes -headache -HTN -confusion What are SEVER HYPOXIA AND IMMINENT RESPIRATORY ARREST clinical manifestations of respiratory failure leading to imminent respiratory arrest? *overwhelming O2 deficit, cerebral O2 affected, CNS changes -dyspnea -bradycardia __b__bronchi __a__nose __b__alveoli __b__bronchioles __a__pharynx __a__larynx __a__epiglottis What are examples of risk factors for decreased resistance/ immunity to respirory infections? *increasing likelihood of developing infection -malnutrition -anemia -fatigue -chilling of body; cold -allergies -bronchopulmonary dysplasia (BPD) -cardiac defects -1 yr olds b/c less IgG, IgM, IgA -daycare -second hand smoke What age during infancy is infection rate increased? why? 3-6 mos b/c decreased maternal antibodies if breastfeed *infants <3 mos get maternal antibodies if breastfeeding What age has higher rate of viral infection? toddler and preschool *increased immunity w/ age What are clinical manifestations of respiratory illness? *varies w/ age -fever -anorexia, vomiting, diarrhea, abd. pain -cough, sore throat, nasal blockage, or discharge -nasal congestion, stridor, crackles, grunting, wheezing What are imporant nursing interventions for all respiratory infections? -maintain respiratory function by airway and nares patent, elevate HOB, supplement humidified O2 -ease respiratory effort by position of comfort, parents close by, head upright position -fever management -rest and comfort by placing in isolation, precautions, good hand hygiene -infection control -promote hydration and nutrition; look at weight and urine output -family support and teaching -meds like ATB and acetaminophen for fever -small frequent feedings unless severe (hold feedings True or false: the nurse should teach family to provide small frequent feedings to maintain nutrition for child w/ severe respiratory distress False! Do this if not severe. If severe hold feedings to decrease risk of aspiration *may need to NG if not getting enough nutrition What is an infection of the upper airway including these 4 types: 1) acute spasmodic laryngitis, 2) laryngotracheobrochitis 3) tracheitis* 4) epiglotittis* What are s/s? Croup syndrome -stridor -barking cough -hoarseness *can cause respiratory distress to respiratory arrest True or false: younger children are more likely to develop croup true T or F: croup is a medical emergency true *may cause respiratory distress and progress to respiratory arrest T or F: viral forms of croup are much more serious false! bacterial are more serious *require frequent monitoring, recognizing worseing s/s T or F: if a child has suspected croup, it is important to inspect the mouth then culture the throat to determine if it is bacterial causing (much more serious) False! NEVER want to throat culture or do visual inspection of mouth b/c may trigger laryngospasms causing airway obstruction Why might airways constrict more and be more severe in younger children? Cartilaginous support not fully developed until adolescence so there is more smooth muscle to constricted airways What is caused when a virus lines the bronchioles causing irritability, airway obstruction, swelling, and excessive mucous production? *most common in infants and young children Bronchiolitis and Respiratory Syncytial Virus (RSV) *diagnose w/ ELISA assay via swab *usually from October to March What nursing considerations and management is used for pt w/ RSV? -manage symptoms -cool mist tent -highly contagious = protective isolation, meticulous handwashing -prevent w/ prophylaxis Palivizumab if high risk (ex: premature, chronic cardiac or lung conditions) -copious amounts nasal secretions = nasal suction What should the family be taught about preventing RSV w/ prophylaxis Palivizumab ? *if high risk ex: premature, chronic cardiac or lung conditions Signature weight loss *can lose weight in bulimia, but it's often much easier to hide What should you assess for pt w/ suspected anorexia? -BMI -electrolyte -cardiac test -mental status -socioeconomic status -skin, hair nails -Cold intolerance -Eating and exercise habits -last menstral pattern -Stool pattern What would the nurse suspect the child is experiencing if they are coughing, in tripod position, wheezing LS? Asthma exacerbation *if no wheezing, look at whole picture. Either means asthma controlled or airway may be closed and in severe distress What is the clinical therapy for asthma? *goal is to maintain asthma control long term, use least amount meds and reduce adverse effects -meds; quick relief and control -peak expiatory flow meter -hydration -education -exercise -support What do all children diagnosed w/ asthma get to individualize care? *tells when to take control med, quick relief med, step up therapy, or go to dr Asthma Action Plan What is an autosomal recessive disorder of the exocrine grands (secrete mucous), impacting multiple systems? *most debilitating disease of childhood in european descent Cystic fibrosis What occurs for CF pts b/c their chloride channels act abnormally in all exocrine glands (secrete mucous)? water does not follow so exocrine secretion (mucous) is thick and viscous; can cause obstruction *respiratory tract, GI tract, and pancreas predominately affected What might indicate CF in infant? meconium ileus (don't pass 1st stool) What are potential clinical manifestations of CF? -cyanosis, clubbing, barrel chest, wheezing, chronic moist productive cough, coarse crackles, SOB -repeated bronchitis and pneumonia -patchy atelectasis "honeycomb lungs" -heart issues -chronic sinusitis/nasal polyps (headaches) -prolapse of rectum -bowel/ intestinal obstruction -stool bulky, frothy, foul, float -liver cirrhosis -DM -fertility issues; delayed puberty females; sterility males -activity intolerance -poor weight gain -salty sweat/skin - dehydration, hyponatremia, hypochloremia, alkalosis, hypoaluminemia What will be evaluated for diagnosis of CF? -infant health screen -DNA analysis -sweat chloride test (salty skin) -chest x-ray -PFT -stool fat and enzyme analysis (for fat loosing) -barium enema (for obstructions) Some CF pts have insulin insufficiency and insulin resistance called CF related DM. Why is it difficult to manage this? Must feed high fat, high calorie food so must use a LOT of insulin The goals for CF are to minimize pulmonary complication, adequate nutrition, prevent GI blockage, and adapt to chronic illness. What treatments are used to help aid this? *think respiratory, GI, pancreas, nasal and sinus cavities Respiratory -high dose ATB (usually IV) -aerosol mucolytics (break up mucous) -bronchodilater (open airway) -anti-inflammatory -percussion and postural drainage -chest vest -exercise GI: -Vitamin A,D,E,K (water soluble form) -pancreatic enzymes (whenever eat) -high cal, high fat, moderate protein -may need supplements of NG feedings -manage GERD -enemas or isotonic fluid lavage (help blockage) -iron (if deficient) -applied behavior analysis -speech therapy -OT (fine motor skills) -sensory integration therapy -family support *early intervention for maximum functioning What is a CNS processing disorder w/ inappropriate behaviors involving inattention? (r/t genetic/environment) *more common in boys ADD/ADHD *ADHD= hyperactivity and impulsivity w/ attention *ADD= deficit in dopamine and norepi lowering ability to tolerate stimulation; hard to focus What are the clinical manifestations of ADD/ADHD? hallmark symptoms 1) decreased attention span 2) impulsiveness 3) increased motor activity also...sleep disturbances, difficulty forming social relationships, anxiety Diagnosis of ADD/ADHD involves a detailed hx and ruling out other conditions. If diagnosed, what is the treatment? multidimensional approach -environmental changes -behavioral therapy -stimulant drugs (ex: ritalin, adderall, concerta) What are potential side effects to stimulant drugs used for ADD/ADHD? How are they managed? -insomnia = give med in morning -anorexia = give w/ meals -potential abuse= keep in locked area and watch administration What is important teaching for parents regarding fevers? -natural defense; if don't look sick dont treat -check temp q 4-6 hrs -give acetaminophen or ibuprofen (>6 mos) -NO aspirin -light layer of clothes -NO sponge baths -lots of fluids and rest What are examples of when the parents should call the HC provider immediately regrading a fever -fever 100.4 if <2 mos -acts or looks very sick -insolable crying or whimpering; cries when moving -difficult to awaken -stiff neck -purple spots on skin -difficulty breathing; doesn't approve when nose cleared -unable to swallow and drooling saliva -seizures What are examples of when the parents should call the HC provider within 24 hrs, regrading a fever -2 to 4 mos old (unless DTaP shot) -fever >104.2 -complains of burning or pain on urination -fever >24 hrs w/out obvious cause of location of infection -fever went away >24 hrs then returned -fever present for >72 hrs How does the nurse assess LOC in an infant? -GCS (eye opening, verbal response, motor response) -AVPU (alert, verbal, pain response, unresponsive) How is GCS used to determine LOC in an infant or nonverbal child? Look at: 1) eye opening =looking around 2) verbal response = smiles, coos, or cries 3) motor response= movement *refer to Table 27-5 GCS How is AVPU used to determine LOC in an infant or nonverbal child? 1) Alert = responsive to parents, cuddles, coos, babbles, smiles 2) Verbal = respond to verbal 3) Pain response= respond to pain only 4) Unresponsive = No response to pain What would you ask to assess orientation in a young child? -What's your name? -Where's your mom? *May be able to answer: Where are we? (doctors or hospital) *NOT expected to know date/time what can cause alterations in LOC? -infection -trauma -poinson ex: lead -seizures -alcohol/substance abuse -endocrine/metabolic disorders ex: DM -electrolyte/acid-base imbalance -brain tumor -stroke -structural defects -discover and correct cause -meds (AED) -ketogenic diet -vagus nerve stimulation -epilepsy surgery What is important for the nurse to do for pharmacological management of seizures -most treated w/ AED; NOT febrile -use single AED -change AED if seizure not controlled or unacceptable side effects -lowest dose -dosage adjustment -monitor drug levels -minimize side effects What AED's may be used for a seizure? -Lamotigine (Lamictal) -Carbamazepine (Tegretol) -Phenytoin (Dilantin) -Phenobarbital -Valproic acid (Depakote) -diazepam (Valium) -loreazepam (Ativan) What are examples of 3 traditional drugs used for: -partial and generalized seizures -reduce nerve's ability to be stimulated -suppress transmission of impulses -MANY, many drug interactions -CNS depressant effects 1) phenytoin (Dilantin) 2) Carbamazapine (Tegretol) 3) Valproic Acid (Depakote) If meds aren't working or not good control for seizures, what might the HC provider recommend? Ketogenic diet; high intake fats, adequate protein, low/no carbs *time consuming; require precise weighting of food; not tolerated by some (>3 yrs) *may hospitazline to monitor glucose and electrolytes What adverse effect may happen to a pt if they are on ketogenic diet to decrease seizure? -constipation -kidney stones -slowed growth What type of seizure treatment is used in children unable to tolerate multiple meds where an implanted device delivers periodic or on demand stimulation to vagus nerve? *press button to stimulate to decrease/prevent seizure Vagus Nerve Stimulation (VNS) *could do neurosurgery instead to remove tumor, lesion, or portion of brain causing seizures, but requires highly specialized process to identify zone What is important nursing management/teaching for pt experiencing a seizure -NO tongue blade; do NOT stink anything in their mouth -get pt down on ground if feel like going to get seziure -put on side -make sure ambubag right size at bedside; suction and O2 working -O2 via humidified mask Where can inflammation affect a pt w/ CNS infections? meninges, brain, or spinal cord *must be identified early and treated rapidly to prevent serious consequences What decreases the incidence of bacterial meningitis? Hib vaccine What is the bodies response when infected w/ bacterial meningitis? *ex: streptococcus pneumoniae, group B strep, Neisseria meningitides 1) infectious agent enters bloodstream, sinuses or ears 2) inflammatory response 3) cerebral edema 4) increased ICP What are risk factors for bacterial meningitis? Who is at greatest risk? *newborns and infants greatest risk; also adolescents going off to college -immunosuppression -VP shunt -cochlear implant -skull fracture -neurosurgery -recent sinus/ear infection What are clinical manifestations of bacterial meningitis? -abrupt onset -nuchal rigidity (stiff neck) -photophobia (sensitive to light) -opisthotonic position -fever -vomiting -diarrhea -altered LOC -headache -bulging fontanelle -muscle or joint pain -hemorrhagic rash to necrosis How is bacterial meningitis diagnosed? Diagnose: clinical features and CSF findings (increased lymphocytes or + CRP) What is the treatment for viral meningitis? Treat symptoms: -acetaminophen (fever and pain) -positioning -decreased environmental stimuli *usually subside by 3-10 days w/ no effects What causes hydrocephalus, an imbalance between volume of CSF produced vs absorbed (excessive CSF)? * r/t impaired absorption, block in flow, or increased CSF production -malformation of ventricles in brain -neoplasm (tumor) - infection -trauma -intracranial hemorrhage (stroke) -scar tissue What are clinical manifestations of hydrocephalus in young children? -large ventricles in brain -large head circumference -frontal region protrusion -translucent skin -wide sutures -prominent scalp veins -sunsetting eyes -signs of ICP (headahce, visual disturbances, N/V, dizziness, sunsetting eyes, pupils not reactive or equal, slight changes LOC and VS, irritability, bulging fontanelle, wide sutures, dilated scalp veins, high-pitched cat like cry) What are clinical manifestations of hydrocephalus in older children? Signs of ICP like: -headache -vomiting -irritability -lethargy -impaired judment -worsening LOC *no head enlargement What is the treatment for hydrocephalus? Surgical implantation of shunt to drain: ex: permanent = ventriculoperitoneal or ventriculoatrial; or ex: short term = ventriculostomy (external drain ) *DO NOT EVER PUMP IT, MILK IT, OR PUSH ON IT Why are numerous revisions typical for child w/ shunt for hydrocephalus? -shunt malfunctions -infection -child growing -clogged What post op care is important for pt after placing shunt for hydrocephalus? -flat position on unoperated side (so don't drain too fast) -prophylactic antiemetic b/c prone to vomiting -measure head circumference q shift -monitor for s/s ICP (headache, vomiting, irritability, lethargy, impaired judgement, worsening LOC, etc) -fluids may be restricted for 24 hrs -CAN play sports, but NEVER contact sports What is the most common developmental disorder of the CNS affecting the head and spinal column? *incomplete closure of verterbrae and neural tubes Neural Tube defects *aka spina bifada What should be advised for women in childbearing yrs to prevent neural tube defects like spina bifada? folic acid (400-600 mcg/day) *ex: fortified grain products or supplements Even thought the cause for neural tube defects like spina bifada is unknown, what maternal factors can predispose child to having? -valproic acid for seizures (take folic acid and change AED) -pre-gestational DM -gestational DM -obesity -folic acid deficiency -hyperthermia (ex: illness w/ fever, hot tub, saunas, electric blankets, work or exercise in sun, and hot environments) If child has spina bifada, where there is an incomplete closure of vertebrae and neural tubes (sac w/ meninges, CSF, and/or nerve roots), then what problems/ deficits may be experienced? *increases the higher the defect in the spinal cord -paralysis or weakness of LE -scoliosis or kyphosis -UTI -incontinence of bowel or bladder -difficult mobility and contractures -anesthesia of skin -skin breakdown How is neural tube defects like spina bifida diagnosed? -prenatal ultrasound -AFP (prentatal testing) 16-18 weeks *indications: dippling, hair tugg, sac Newborns w/ neural tube defects like spina bifida usually have surgery to close defect. What nursing interventions are important prior to surgery? -coagulation defects -degenerative joint disease What are children more prone to as a result of airway developmental differences? -infection -nares easily occluded -obstruction -aspiration -less able to compensate for edema, spasm, and trauma -edema and obstruction -thyroid, cricoid, and tracheal cartilage may easily collapse T or F: children have a shorter trachea and the angle of right bronchus at bifurcation more acute, increasing risk of foreign body aspiration true Children have 4 mm of diameter in airway, if 1 mm of inflammation and swelling occurs=narrowing the airway to 2 mm, causing increased airway resistance. What must the child do to compensate for this? *doesn't affect adults as much b/c 20 mm so becomes 18 mm Use more effort to breathe and must breathe faster to get adequate O2 *refer to "patho: airway diameter" What occurs as a result of the immature chest muscles and ribs of cartilage? more flexible = retractions when in distress *mild=ICS retractions *moderate= substernal and subcostal retractions *severe=supraclavicular and suprasternal retractions *refer to "patho: retraction sites" What is the nurse concerned about if pt presents with the following symptoms: sitting up or in tripod position, tachypnea, adventitious breath sounds, stridor, retractions, nasal flaring, paradoxical breathing, coughing? Respiratory distress *refer to "assessment guide: child in respiratory distress" What are risk factors for SIDS? -preterm, low birth weight, SGA, multiple birth -native american and African american -males -maternal smoking, alcohol abuse, or substance abuse -socioeconomic disadvantages -prone or side lying position -bed sharing -soft bedding, pillows, blankets, stuffed animals -overheating -secondhand smoke *refer to Table 20-3 "Risk factors for sudden infant death" What is important information for parents taking care of infant w/ mild bronchiolitis? ex: RSV -bulb syringe to suction nares <1 yrs -fluids (thin secretions) -calories (for energy) -encourage rest and naps call physician if: -symptoms interfere w/ sleeping and eating -symptoms persist if <1 yr, heart or lung disease, or premature w/ lung disease -breathing rapid or difficult -acts sicker (tired, less playful, less interested in food) What do the different zones indicate for Peak Expiratory Flow Meter? *refer to "families want to know: peak expiratory flow meter" -Green zone: PEFR 80-100%; control good -Yellow zone: PEFR 50-80%; follow asthma action plan--usually quick relief; call dr if not imporved -Red zone: PEFR <50%; urgent quick relief med; call dr for additional care or take to ER *measure 2x/day for 2 weeks What adverse effects is characterized by head bobbing, tics, grimacing, rapid involuntary jerking, flinging proximal muscle groups, and slow writhing movement? It occurs from use of Parkinson's meds like: -levedopa -levedopa/carbidopa -dopamine agonists (fewer incidences) -levedopa/COMT inhibitors [ex: entacapone] -levedope/MAOB [ex: selegiline] Dyskinesias Match the following Parkinson's med? 1)____fewer incidences of dyskinesias and "wearing off" syndrome; serious side effects like hallucinations, daytime sleepiness, ortho hypo, sleep attacks, and compulsive behaviors; don't drive if any of these symptoms 2) no direct therapeutic effects on own; used only in conjunction of levedopa; do NOT abruptly stop; by itself causes fewer adverse reactions like vomiting, diarrhea, constipation, yellow-orange urine 3) converted to dopamine; most effective drug for PD; effects like N/V, dyskinesias, ortho hypo, psychosis,CNS effects, dark sweat urine avoid taking w/ high protein meals; full effects take several months; effects diminish over time; stop if dyskinesia 4) combo superior; no adverse effects on own; adverse effects from levedopa; psychosis and abn movements sooner and more intense; take before meals; hold if hypotension; check BP 5) reduces tremor but not bradykinesia; a Pt has admitted for 24 hr stay to evaluate after falling off 12 ft later. CT showed subdural hematoma and closed head injury. What is the nurse most concerned about? Incrased ICP (look for changes in LOC, visual disturbances, N/V, etc) Pt being pbserved ford 24 hrs after falling from 12ft later. The wife informs the physican that her husband has hx of afib on warfarin, and renal disease but not on dialysis. What are concerns r/t to this information? -pt needs multiples CT's to assess for injury. Contrast is used to provide detailed picture; contrast is very hard on kidney and can push pt into acute renal failure; it is important to be carefule and give fuids to help flush dye out -draw PT/INR then give vitamin k to reverse anticoagulant effects of warfarin Pt admitted for 24 hr observation ifrom closed head injury w/ subdural hematoma. Pt GCS was taken at admission and was 14, upon later assessment, it is now GCS. What is the RN's next action? -call rapid repsonse b/c may be re-bleeding and increased ICP -look for indicators of bleeding= irritable, restless, changes in pupils Why might Mannitol (Osmitrol) by prescribed for pt admitted after fall from 12 ft ladder, experiencing subdural hematoma, GCS changes from 14 to 10, then presents signs like irritable, restless, and changes in pupils? What else might the physician prescribe? Pt experiencing increased ICP: -will pull water out of extracellular space of brain full of edema to treat ICP by increasing perfusion -can give lasix to enhance effects What nursing assessment/interventions when a pt receives Mannitol and Lasix -Strict I & O; get foley w/ graduated cylinder -monitor electrolytes (k+ levels) -assess for s/s of dehydration -assess for edema; call dr if occur What discharge teaching would the nurse provdie for a pt after TBI? -personality will change (ex: hostile, positive, mean, super nice) -could be impulsive--don't leave home alone -TBI therapy -safety in home -OT/PT home evaluation -may change sense of smell (ex: can't tell house on file) -many resources available What might be occuring if pt was admitted for TBI, and is experiency yellow fluid in ears? What should the nurse do? Halo sign *CSF leaking from possible puncture *big risk for infection *figure out where coming from, clean, put gauze on Pt presents to ED w/ right sided facial drooping, right arm/leg flaccid, slurred speech and dull prick to RLE. Based on the deficits which hemisphere has been affectred by stroke? Left hemisphere *since speech affected, shows left is the dominant side/hemisphere Upon arrival to ED, pt was confused but alert and able to state name. 24 hrs later pt has expressive aphasia and is unable to communicate verbally or in writing. Why is this occuring? What should be done for this pt? -NEVER know extend of damage causing deficits from stroke for up to 72 hrs *Do a CT scan on presentation, then follow up CT scan for progression *Nurse's priority is to do a very detailed neuro assessment (including CN nerves What are the 6 clinical manifestations that the nurse should be assessing for, indicating a stroke? 1) sudden severe headache 2) confusion or changes in mental status 3) difficulty walking, loss of balance, dizziness 4) trouble speaking, slurred speech, difficulty understanding speech 5) weakness or numbness of face, arms, or legs 6) visual disturbances What stroke signs should be taught to lay person/family/pt? F=facial drooping A=Arm weakness S=speech T=time to call 9-1-1