Pediatric CCRN - Hot Spot Notes: Critical Care Nursing Exam Preparation, Exams of Nursing

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Pediatric CCRN - Hot Spot Notes CRUNCH TIME BETCH

Questions with Answers

How do you calculate Serum Osmo - Correct Answer (Na x 2) + (Glucose/18) + (BUN/2.8) Becks Triad for Diagnosing Tamponade - Correct Answer - JVD

• Hypotension (huffled heard tones)
• Tachycardia
• Narrowed Pulse Pressure Right Ventriculogram via Cath shows: - Correct Answer RV Size, Function, and Structure RVOT Tricuspid Regurg PA Anatomy Pulmonary Venous Return to Left Side of Heart Left Ventriculogram via Cath Shows: - Correct Answer LV size, function, structure Outflow Tract Left to Right shunting patterns Aortagram via Cath Shows - Correct Answer Aortic Arch Structure Aortic Regurg Coronary Anatomy SvO2 Monitoring - Correct Answer Normal is 60% to 80% Low SvO2 = Low CO ----- OR ---- Increased demand (fever, infection...)

O2 consumption (VO2) indirectly reflects ____? - Correct Answer Tissue demands CaO2 - PvO2 = VO PA line is used for intermittent analysis of PVO2. Impending Respiratory Failure seen when...... - Correct Answer PCO2 > 50 and raising by 5 per hour. Pulmonary HTN can be associated with..... - Correct Answer Fatigue Hepatomegaly Accentuated S2 sound In PPHN there is __________ RV pressures due to shunting of blood from the __________ to the _______? - Correct Answer Increased PA Aorta Heliox is _____ density that is ______ turbulent than oxygen - Correct Answer lower less Leukotriene Inhibitors are part of long term management of asthma. Takes ______ hours to take effect. - Correct Answer 24. Thus not an emergent rescue treatment. Acysteinyl Leukotriene causes broncho ________, mucus secretion, __________ vascular permeability and eosinophils to migrate to the airway. - Correct Answer constriction Increased Anion Gap Calculation - Correct Answer (Na - K) - (CL + HCO3) Different between the positive and negative ions Normal Anion Gap - Correct Answer 10 to 12

What type of arrythmia is expected one day post op heart Cath for repair of an ASD? - Correct Answer PACs Early Stages of Septic Shock - Correct Answer Increased Cardiac Output Decreased SVR Flushed, warm extremities, bounding pulses, and widened pulse pressure Patients with myelomeningocele are prone to ______? - Correct Answer Constipation and Impaction They are also unable to control BMs, are required to have more activity to increase bowel movements, and need to have a BM every day. Prior to administering Dig assess: - Correct Answer Serum Potassium and PR Interval Potassium and dig Fact! - Correct Answer Hypokalemia can aggravate digoxin cardiotoxicity, even in the presence of therapeutic levels of digoxin. Most serious adverse effects of digoxin toxicity? - Correct Answer Arrhythmias - including heart block - which may be indicated by an abnormal lengthening of the PR interval. Multiple Organ Dysfunction Syndrome (MODS) progression - Correct Answer Circulatory collapse - > Respiratory Failure - > GI tract and liver failure - > Renal failure - > neurological Dysfunction Mannitol (osmitrol) is administered to a patient with a head injury to: - Correct Answer Raise Serum Osmolality Produces both osmotic and vasoactive effects that decrease intercranial hypertension, likely related to its theologic properties resulting in a shift of water from the cellular to the extracellular spaces. The subsequent diuretic phase drains water with the medication to be excreted in urine, resulting in a higher serum osmolality.

The sequelae of chronic hypoxemia includes: - Correct Answer Increased PVR Pulmonary Hypertension Cor Pulmonale BPD is a response of _____? - Correct Answer An immature lung to early injury occurring in premature infants and leading to ventilation-perfusion mismatch, which results in hypercarbia and hypoxemia. Small # of alveoli which are large in size. Fact: Hyperphosphatemia develops as a result of a reduction in the GFR. As glomerular filtration rate falls, more phosphate is transported actively out of the tubules and returned to the circulation. - Correct Answer Fact: Once acute kidney injury develops, the ability of the kidneys to regulate fluid volume and potassium, calcium, and glucose concentrations is severely impaired. - Correct Answer Hyperkalemia develops because _______ tubular injury impairs potassium secretion, and formation of urine, resulting in decreased potassium secretion. - Correct Answer Distal Hemolytic Uremic Syndrome (HUS) Triad - Correct Answer Anemia Thrombocytopenia Renal failure with associated hyperkalemia Dilated Cardiomyopathy - Correct Answer Depressed cardiac function due to remodeling and progressive ventricular dilation resulting in pooling of blood in the heart chambers, resulting in increased chamber pressure. Tricyclic Antidepressant OD Symptoms - Correct Answer - Depressed LOC

• SZ - rapid onset of grand Mal seizures w/in 30 mins of ingestion
• Life threatening arrhythmia - prolonged PR and - QRS intervals.

• Acidosis Dry mouth is associated with anticholinergic effects. The progression of early signs of HTN to hypotension is associated with soda channel blockade and cardiac arrhythmia Activated Charcoal Q4 until asymptomatic What is the single best test to evaluate DIC? - Correct Answer Fibrin Split products or Fibrin - related markers There is elevation of the fibrin split products in acute and chronic DIC FACT: Chronic Renal Failure is an irreversible, progressive process that leads to end- stage renal disease (ESRD), defined by damage for three months or more and glomerular filtration rate (GFR) less than 60 ml/min per 1.73 m2 of BSA - Correct Answer Fact: Slipped capital femoral epiphysis is a spontaneous displacement of the proximal femoral epiphysis. It occurs most frequent with accelerated growth and onset of puberty. - Correct Answer What antibody therapy leads to increased survival of platelets? - Correct Answer Anti-D Antibody therapy What dysrhythmia is associated with device closure of a ventricular septal defect within days of the procedure? - Correct Answer Third degree AV block. Symptoms that suggest Hemolytic Anemia - Correct Answer Jaundice, dark urine from hemoglobinuria, splenomegaly, hepatomegaly, a flow murmur, and fatigue The presence of dark urine is indicative of RBC destruction. Parland formula for fluid resuscitation in burns - Correct Answer 4 ml of LR x % of TBSA burned x Wt (Kg) = 24 hour volume

1/2 in first 8 hours Second half in next 16 hours Quincke Sign - Correct Answer Pressing on nail bed and see visible pulsation. Indication of aortic insufficiency. ADH, which is stored in the _____________, allows the renal collecting ducts to become ________ permeable to water creating a ______ concentrated urine. - Correct Answer Posterior Pituitary More More FACT: In DKA the breakdown of the blood brain barrier occurs due to the presence of ketones and decreased perfusion. - Correct Answer Trauma can cause ________ DI when there is edema on of the hypothalamus can lead to decreased secretion of ADH. - Correct Answer central ECG in hypokalemia - Correct Answer U waves, Inverted T waves and ST segment shortening ECG in hyperkalemia - Correct Answer Shortened QT interval Acute PE - Correct Answer When PE obstructs the pulmonary capillary bed, RV after load increases and leads to RV dilation causing decrease in coronary perfusion. PA pressures increase Size and Location - decreased distal blood flow - degree of obstruction will determine result Fact: Extravasation of CA chloride can cause tissue necrosis. - Correct Answer

Fact: Corticosteriods decrease the number of cells available to participate in the inflammatory response by decreasing the mitigation of neutrophils and monocytes. By Decreasing vasculature permeability, the movement of cells from vascular space to tissues in prevented. - Correct Answer Intrinsic Renal Failure - Correct Answer Describes numerous conditions which produce renal parenchymal damage involving the glomerulus or tubular epithelium Phenochromocytoma - Correct Answer Is a catecholamine secreting tumor that leads to HTN, HAs, and palpitations. Pallor is caused from extreme vasoconstriction.

• Can develop anywhere in the body and does release epinephrine and norepinephrine into circulation.
• In children, it releases more norepinephrine than epi
• The urine does contain elevated catecholamine levels. Myoglobinuria - Correct Answer (Often seen in crushing injuries) Usually associated w/ rhabdomyolysis, or muscle destruction.
• Accompanied by an increase of CK
• May cause tubular obstruction and acute renal insufficiency
• Release of potassium, phosphorous, and thromboplastin Serotonin Syndrome - Correct Answer Autonomic and neuromuscular effects (Fever, tachycardia, and muscular rigidity)
• Ascending neuromuscular effects may lead to respiratory compromise
• Treatment includes respiratory support, aggressive external cooling, and treatment of muscular rigidity as needed, w/ measures ranging from bentos to muscular paralysis Hemophilia B is managed with ______ - Correct Answer recumbent Factor IX Hemophilia A is managed with _______ - Correct Answer DDAVP and Factor VIII

When labs indicate a shift to the RIGHT it indicates an increase in _________ - Correct Answer Mature Neutrophils or polys When labs indicate a shift to the LEFT it indicates an increase in ________ - Correct Answer Immature Neutrophils or Bands ANC levels - Correct Answer 1500 - 2000 = NORMAL 1000 = Moderate risk of infection 500 = Severe Risk of infection The ileum absorbs _________ and vitamin _____. - Correct Answer Bile Salts and Vitamin B The small intestine absorbs _______ and ______. - Correct Answer Amino acids and proteins The duodenum absorbs _______ and _________ soluble vitamins. - Correct Answer Iron and Water soluble vitamins The descending colon absorbs ______ and _______ - Correct Answer Water and Electrolytes The gallbladder concentrates _____ - Correct Answer Biles The liver forms _________, stores _______ and ______ soluble vitamins, and breaks down _______. - Correct Answer The liver forms clotting factors, stores glycogen and fat soluble vitamins, and breaks down proteins. pH Probe and GERD - Correct Answer A pH Less than 4 for 15 seconds or more is considered diagnostic of GERD.

Octreotide - Correct Answer Reduces portal venous pressure. It decreases blood flow to the spleen and has vasoconstrictive properties. It also inhibits the synthesis of gastrin and gastric acid. Fact: Antibiotic prophylaxis is needed when the spleen is removed - Correct Answer Fact: Respiratory Distress and Acidosis are associated with bowel perforation - Correct Answer Lactulose - Correct Answer Eliminates ammonia by making the intestinal flora more acidic Hepatitis - Procteric Stage - Correct Answer - Lasts for 1 week

• Symptoms: fever, chills, anorexia malaise, ABD pain, N/V, joint pain, hepatomegaly, lymphadenopathy. Hepatitis - Icteric Stage - Correct Answer - Lasts 2 - 6 weeks
• Symptoms: Weakness, fatigue, pallor, jaundice, dark urine, pale colored stools, pruritus, palmer erythema (itchy red palms) Hepatitis - Posticteric Stage - Correct Answer Resolution of jaundice and normalization of stools and LFT values Hypoglycemia Treatment - Correct Answer 0.2 to 2g/kg Dextrose 5 - 20 ml/kg D10 - may administer PIV 2 - 4 ml/kg D25 - must be administered centrally DKA triad - Correct Answer - Hyperglycemia (>180)
• Ketonuria/ketonemia
• Acidosis (pH <7.3, HCO3 <15) DKA clinical manifestations - Correct Answer Increased K

Increased Phos Increased Sodium DKA treatment - Correct Answer Insulin 0.05 - 0.1 u/kg/hr Glucose: Add 5% dextrose when BG 300 Add 10% dextrose when BG 200 Drop no faster than 50 - 100 /hr Left Heart Failure - Correct Answer Decrease in CO secondary to decreased contractility LV is unable to completely empty during systole. Back flow of blood from LV to the LA Right Heart Failure - Correct Answer Right heart failure often occurs as a progression of left heart failure. Causes: PHTN, RV infarct, cardiomyopathy Manifestations: JVD, Increased CVP and PVR, Ascites, Peripheral Edema, Hepatosplenomegaly. Dilated Cardiomyopathy - Correct Answer Most common type of cardiomyopathy in children Massive cardiomegaly and LV dilation Referred to as "Congestive" Cardiomyopathy

Decreased SV and EF, decreased CO r/t poor contraction. Increased Systolic and Diastolic volumes. Stasis occurs. Hypertrophic Cardiomyopathy - Correct Answer Increased myocardial mass (THICK), particularly in the LV with decreased ventricular cavity size. Resistance to LV filling. Diastolic stiffness of LV impairs filling producing atrial enlargement. Blood flow is obstructed - > hypertrophic tissue - > left ventricular outflow tract obstruction BIG, THICK, UGLY HEART Inotropes with stress and exhaust the muscle Restrictive Cardiomyopathy - Correct Answer Not common in Peds.

• Defect of the anatomy in the endocardium
• Related to fibrosis and scarring of the ventricle
• Resulting in minimal contractile movement, poor ventricular compliance, and inadequate filling.
• NORMAL systolic function, but DECREASED diastolic function Acute Respiratory Failure - Correct Answer Inability of the respiratory system to meet the demands of the body for Oxygen. Inability to provide adequate Co2 elimination Acute Respiratory Distress Syndrome - Correct Answer The lungs are injured by infection, disease, fluid aspiration, burns, inhalation, or fat embolism. Progressive hypoxemia is seen. Blood and fluid leak into alveoli of injured lungs, preventing oxygen from entering alveoli. Inflammation of lungs lead to scar tissue formation.

Bilateral Pulmonary infiltrates seen on CXR. Permissive Hypercapnia - Correct Answer A higher PaCO2 with normal oxygenation, pH

7.2, and no evidence of cerebral dysfunction Acute Pneumonia - Correct Answer Infection of the lung usually caused by viruses or bacteria. Cycle: Invading organism - > inflammatory response - > alveolar edema - > generalized pulmonary inflammatory response. Lung consolidation - > reduced compliance - > decreased total lung capacity. Acute Laryngotracheobronchitis - Correct Answer Croup Prevention for Epiglottitis - Correct Answer HIB vaccine Congenital Diaphragmatic Hernia (CDH) - Correct Answer Herniation of abdominal contents into thoracic cavity in utero. Heart is displaced to the right. Growth and development of both lungs affected. R to left shunting Scaphoid Abd Preoperative position - Semifowlers Choanal Atresia - Correct Answer Congenital disorder where the back of the nasal passage is blocked by abnormal bony or soft tissue formed during fetal development.

Tracheomalacia - Correct Answer Widening of the posterior membranous wall of the trachea, and reduced anterior-posterior airway diameter. Tracheal Stenosis - Correct Answer Idiopathic Traumatic secondary to accidents, intubation, or chemical inhalation Diagnosis of Brain death - Two exams separated by an observation period... Time frames - Correct Answer Term Newborn - 30 days old = 24 hours Infants and children - 12 hours Encephalopathy - Correct Answer Any neurological disorder of unknown or noninfectious cause Diagnosis: LP is negative, good history and physical exam Treatment is supportive and decrease ICP Status epilepticus - Correct Answer Prolonged seizure or multiple consecutive seizures without regaining consciousness

30 minutes or longer Partial Seizures - Correct Answer (focal/local) Begin focally from a single lovation within one hemisphere Simple partial - no impairment or loss of consciousness Complex partial - impairment of consciousness present Generalized Seizures - Correct Answer (convulsive or nonconvulsive)

Absence (petit mal) - staring, "Space" Myoclonic - sudden, brief, generalized muscle contractions Febrile Seizures - elevation of temperature greater than 101.8 affecting children ages 6 months - 6 years Myoclonic infantile Spasms - Correct Answer Head bobbing or body jerking Affects ages 3 to 8 months Clonic Seizures - Correct Answer Tremor leading to violent shaking Tonic - Correct Answer Elbows and arms rotated, legs extended, eyes open, cyanosis, loss of bowel and bladder control Tonic-Clonic (grand mal) - Correct Answer Both clonic and tonic symptoms.... Treatment of seizures - Correct Answer Diazepam/Lorazepam INITIAL treatment

• Onset minutes, half life 7 minutes Phenytoin
• onset 15 - 20 minutes, therapeutic level 15 to 20 minutes
• Side Effects: cardiovascular collapse if administered rapidly CSF in a patient diagnosed with a subarachnoid hemorrhage? - Correct Answer Bloody at first; if done 5 days after hemorrhage, it would be dark amber (xanthochromic) due to the breakdown of blood cells Encephalocele - Correct Answer Protrusion of nervous tissue through a deficit in the skull

Acute Abdomen - Correct Answer Refers to sudden onset of abdominal pain and tenderness. Needs evaluation for surgical intervention Kasai Procedure - Correct Answer is a surgical procedure where an artificial biliary tree is made from the jejunum to drain bile from the liver to the duodenum NOTE: A sodium level of 135 mEq/L would indicate that Na+ levels are returning to normal and SIADH is reversed. - Correct Answer NOTE: In DKA glucose is unable to enter the cells. Rising Serum glucose levels. Alternative metabolic pathways activated. Fat and Protein metabolized for fuel. Results in cellular energy deficit. Serum Osmo is elevated due to massive osmotic diuresis. - Correct Answer Glucogenesis - Correct Answer Glucose formed from amino acids and proteins Common amino acids administered for metabolic deficiencies - Correct Answer arginine Disseminated Intravascular Coagulopathy (DIC) - Correct Answer Fibrinogen converted to fibrin in setting of increased platelet aggregation. Clotting - rapid, widespread formation of fibrin thrombi in microcirculation. Leads to ischemic injury. Organ dysfunction - brain, kidney, liver, or lung injury. Bleeding - clots are lysed, consumption of clotting factors, fibrinogen, platelets. Eventually blood loses its ability to clot. Labs in DIC - Correct Answer Prolonged PT and PTT Thrombocytopenia Decreased Fibrinogen Increased D-Dimer Decreased coagulation factors Increased fibrin degradation products

Treatment of DIC - Correct Answer Treat underlying cause. Administration of Blood products Heparin in early thrombotic phase (controversial) **Clotting factors = FFP/cryo Idiopathic Thrombocytopenic Purpura - Correct Answer Develop antibodies to own platelets Increased peripheral platelet destruction Diagnosis of exclusion - rule out everything else first. Exact cause is unknown - often precipitated by a viral infection. Labs: Decreased Platelet Count Normal PT/PTT Heparin-Induced Thrombocytopenia (HIT) - Correct Answer Anitbody mediated complication of heparin exposure that increases risk of thrombosis Caused by abnormal antibody formation - platelet activation Initiates the formation of blood clots Platelet count decreases because of consumption Expect it when you have an unexplained platelet decrease by 50% of baseline. Passive - Natural Immunity - Correct Answer Acquired via natural contact with antibody transplacentally or via colostrum and breast milk Passive - Artificial Immunity - Correct Answer Acquired through the administration of antibody or antitoxin

Ex: tetinus shot Active - Natural Immunity - Correct Answer Acquired via natural infection; exposure to antigen and immune response mounted Active - Artificial - Correct Answer Acquired via inoculation with a variant antigen Ex: immunizations Immunodeficiency - Correct Answer A permanent state of impaired immune function that is usually genetic or congenital in nature Immunosuppression - Correct Answer A state of impaired immune function that can be intentional or unintentional in nature Severe Combined Immunodeficiency - Correct Answer Most severe combined B- and T- lymphocyte disorder Immunologic emergency Survival requires stem-cell transplant Unusual frequency of common infections Tumor Lysis Syndrome - Correct Answer Most common metabolic emergency in oncology patients. Metabolic triad

• Hyperuricemia
• Hyperkalemia
• Hyperphosphatemia Patho- Rapid release of intracellular contents

Large Tumor Burden Rapid Cell Turnover Rapid Response to tumor therapy Spinal Cord Compression - Correct Answer Impingement of the spinal cord or cauda equina Intramedullary mass (Primary CSN tumor) Compression of the thecal sac (tumor in the epidural space) PAIN - when laying down, but improves when standing up. Rapid intervention needed to minimize the irreversible side effects Corticosteroids to decrease swelling leading to injury Acute Hemolytic Transfusion Reaction - Correct Answer Delayed reaction after starting transfusion. Anaphylaxis is typically seen within a few minutes of initiating transfusion Fact: D dimer is a byproduct of fibrin - Correct Answer Recognizing SIRS - Correct Answer In children ONE of the qualifying diagnostic criteria must be Temp or WBC Temp of >38 rectal or <36 rectally Tachycardia Tachypnea or a PaCO2 level < 32 Abnormal WBC count >12,000 or <4,000 or >10% bands

Blood Volume - Correct Answer 70 - 80 ml/kg of body weight Diagnosis of VAP - Correct Answer Can occur 48 hours post extubation Neuroleptic Malignant Syndrome - Correct Answer Life Threatening Event Can develop symptoms after initiation of or increased dose of a neuroleptic medication - haloperidol [haldol] Treatment: Stop medication IV Hydration Treat Hyperthermia RIFLE criteria (Renal Disease) - Correct Answer R - Risk of renal Dysfunction I - Injury to the Kidney F - Failure of kidney function L - Loss of kidney function E - End Stage Kidney Disease Phases of Renal Failure - Correct Answer ODR Oliguric Phase Diuretic Phase Recovery Phase Oliguric Phase of Renal Failure - Correct Answer Determines the type of Failure

• Abrupt decrease in UOP <1 ml/kg/h
• Increased BUN/Cr
• USG <1.
• Decreased urine osm

• Urine Na >
• Related to tubular dysfunction and inability to concentrate urine
• Complications - hypervolemia, electrolyte imbalances (Increased K, Decreased Ca), Acid-Base Imbalances - Metabolic acidosis Diuretic Phase of Renal Failure - Correct Answer 5 - 7 days
• BUN increases then decreases Fluid imbalance Electrolyte imbalance Acid-base imbalance GFR recovers first Recovery Phase of Renal Failure - Correct Answer 2 - 4 months Lasts longer in children than in adults BUN normalizes Variable level of recovery Hemolytic Uremic Syndrome (HUS) - Correct Answer Patho - Toxins - > vascular endothelial damage - > cells swell - > widened subendothelial space - > glomerular swelling - > fibrin deposits - > thrombosis of arterioles - > renal ischemia - > ARF Note: In prerenal failure, oliguria is the body's compensatory mechanism to retain more fluid, increase intravascular volume, and thereby improve tissue perfusion - Correct Answer Note: Lactic acidosis can cause an increase in the anion gap - Correct Answer Acute Tubular Necrosis - Correct Answer Death of the tubular cells leading to changes in glomerular permeability where it is increased for proteins and decrease for potassium.