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270 Cards in this Set
- Front
- Back
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General s/s of depression
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Psychomotor retardation
Flat affect Negative interpretation of events Crying |
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What to do about suicidal ideation
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Questions: When? Where? Means?
Don't leave alone Document Call MD Thank pt. for telling |
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Onset for most antidepressants
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2-3 weeks (teach)
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Proirity for auditory hallucinations
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Safety
Ask: What are they telling you (commands?) |
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Some symptoms of schizophrenia
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Auditory, visual, tactile hallucinations
Speech: loose associations, word salad, neoglisms Incongruent mood with emotional context |
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What might you see in someone on antipsychotics?
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Rigid jaw, slurred speech, severe extra pyramidal sides (Risk of laryngospasm - give meds IM)
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Features of tardive dyskinesia
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Darting tongue mvmts.
Pursed lips Grimace |
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Features of neuroleptic malignant syndrome
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Excessive sweating at temples
Rigidity |
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What two things should be avoided when taking an MAOI?
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Tyramine
OTC cold mds |
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Major side effect of Clozarine (Clozapine)
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Agranulocytosis
(spend lots of $ on bloodwork |
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Things to know when taking antianxiety meds
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Do not stop abruptly
Risk of withdrawal, physical dependency |
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What if there is a religious ritual going on in a room?
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Come back later
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Irrational thoughts in psychotic/manic depressive/schizophrenic patients?
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Delusions (Grandiose, etc.)
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Teaching for pt on Lithium
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Frequent blood work (dangers of toxic levels)
Normal salt & H2O intake No saunas |
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Difficulties of adult children of alcoholics
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Trust
Depression Codependency Intimacy |
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What to assess to determine if a pt will experience a crisis
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Coping Mechanisms
Support System Perception of Event |
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Reasons for multi-generational transition of child abuse
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Lack of education re. growth and development
Violence is familiar M.O. Knowledge deficit re. normal growth & development |
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Stages of group therapy
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Introduction (superficial)
Working (more in-depth, real issues) Termination (talking about next step - split) |
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When dealing with a manipulative PT
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Set Limits
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Theraputic relationships are
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Patient centered
Boundries Time limited Goal oriented (contracts) |
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Why breastfeed a just delivered baby right away?
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The baby is awake and ready
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Test used to diagnose pregnancy
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HCG (Human Chorionic Gonadotropin)
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Med to inhibit/stop contractions in pre-term labor
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Ritodrine (Yutopar)
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Risk for pregnant woman with Hx of PID (Pelvic Inflammatory Disease)
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Ectopic pregnancy (r/t scar tissue)
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An increase in the amount of bloody show during labor means
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Cervix dilating more
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OK to push when not fully dilated?
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No (pant/blow instead)
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1st stage of labor
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First true contraction to full dilation
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2nd stage of labor
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Full dilation to birth
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3rd stage of labor
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Birth to placenta delivery
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"Nurse! The baby is coming!" What do?
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First look at perineum and see if it's true
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When is it ok to eat after a C section?
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When you hear bowel sounds
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When is RH incompatibility most likely?
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RH - Mom
RH + Baby |
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Mom RH -
Dad RH |
RH+ Baby
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What should a jaundice baby wear under lights?
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Eye patches, maybe diaper
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What is a rash develops on a jaundice baby wear under lights?
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it's OK - expected
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What organ in a baby is most susceptible to jaundice?
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Brain
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Associate which population with Tay Sachs
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Jewish
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Temp increase in a post-partum mom can mean
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Dehydration
*Later = Infection |
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Most common cause of early post-partum hemorrhage
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Uterine atony
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Too much O2 use in a premature baby can cause
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Retrolental fibroplasia
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What kind of defect does a Down's syndrome baby have?
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Chromosomal (extra one)
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Smoking during pregnancy leads to
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Low-birth weight
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Three parts of stage one during labor
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Latent Phase - 0-3cm dilation
Active Phase - 4-7cm dilation Transitional Phase - 8-10cm dilation |
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What do variable decellerations on the monitor mean during labor?
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Cord compression
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What do late decellerations on the monitor mean during labor?
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Utero-placental insufficiency (not enough 02)
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What do we see with LOP positioning
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Back pain
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Weight gain during pregnancy
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25-35 lbs
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What if the fundus is elevated and higher to one side in a post-partum mom?
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Empty bladder
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What if the fundus is in place and firm in a post partum mom - but she's bleeding?
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Laceration
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What to eat to increase folic acid intake
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Dark leafy greens
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When is iron best absorbed?
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Between meals and with Vitamin C
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Measurement at 18wks. pregnant
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18cm
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Position after eating for heartburn
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Upright
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Non-stress test
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Fetal heart rate should increase when baby moves
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What do you not want to see during a contraction stress test (ie. w/ pitocin)
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Late decellerations
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Mom has a yeast infection (Candidiasis) - baby may have ...
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Thrush
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What does a cold baby use up quickly?
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O2 and Glucose
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Small amt. of spotting (blood) noticed when changing a baby girl is ...
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Normal
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Inside the umbilical cord are...
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two arteries & one vein
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Birth process for a mom with active herpes
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C Section
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Changing cat litter while pregnant? Risk for...
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Toxoplasmosis
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Why is amniosentisis done early?
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To check for chromosomal problems
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Why is amniosentisis done late?
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To check lung maturity
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Signs of pre-eclampsia
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BP increase
Proteinuria Edema/weight gain |
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What to watch for in a person with pre-eclampsia
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Severe gastric pain = impending seizure
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What's Acute Glomerulonephritis
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antigen antibody that follows an infection caused by group A beta-hemolytic strep (strep throat, impetigo)
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Assessment for Acute Glomerulonephritis
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Hx or URI or skin infection 1-3 weeks before
See cola (smoke, tea) colored urine Slight edema around eyes (usually in am) & loss of appetite Temp. (may be 104) Maybe elevated BP (assess frequently) HTN encephalopathy / can result in neurological sym. (dizziness, HA, photophobia) |
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Lab results for for Acute Glomerulonephritis
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oliguria and hematuria
Urine has albumin, RBC *(differentiates from nephrotic syndrome)* , WBC, casts, increased specific gravity elevated BUN, Creatinine *(elevated creatinine most specific for renal failure)* |
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Nursing Management for Acute Glomerulonephritis
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Bedrest during acute phase
Protect from: chilling, fatigue, and infections Check VS Q4hours (report elevated BP & signs of cerebral ischemia) - if marked edema or elevated BP (moderate salt restriction) - if severe kidney involvement (may limit protein) - output greatly decreased (ice chips, fluid restriction) weigh daily (wt. loss is due to decrease edema) avoid or treat any respiratory infections stat avoid sports until no microscopic evidence of hematuria or proteinuria |
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General Info about Acute Rheumatic Fever (ARF)
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Leading cause of acquired heart disease in children
autoimmune d/o with connective tissues such as heart, joints, CNS Children: previous Group A beta-hemolytic strep infection |
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Major assesment criteria for Acute Rheumatic Fever (ARF)
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Migratory Polyarthritis *(most common)*
occurs first 1-2 weeks lasts for few days certain joints before moving to other areas Favors lg. joints (knees, hip, elbow) Carditis -ONLY SYMPTOM THAT MAY CAUSE PERMANENT DAMAGE Chorea sudden muscular movements, involuntary (facial grimacing, emotional labile, muscle weakness, speech disturbance) Erythema marginatum chicken wire appearance Subcutaneous Nodules small non-tender nodules over bony prominences |
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Minor assesment criteria for Acute Rheumatic Fever (ARF)
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Arthralgia, low grade fever (highest in afternoon) fatigue
Elevated ESR, Elevated C reactive protein Elevated ASO titer *(most reliable evidence child had strep)* |
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Medical Management of Acute Rheumatic Fever (ARF)
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Anti-inflammatory drugs - asa and steroids (give w/ meals)
PCN (erythromycin if allergic) 10 days (give prophylactically for years) Increase AB tx before dental or medical procedures |
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Nursing Management of Acute Rheumatic Fever (ARF)
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Bedrest *(highest priority) minimize cardiac damage
Assess AP (very important) allowed OOB when ESR returns to normal and C-reactive protein disappears Decrease pain from carditis and polyarthritis (anti-inflam) Bed cradle Handle gently Prevent injury from chorea (no forks or anything sharp) Evaluate regression or progression of disease check I&O daily weight Assess SLEEPING AP * (with elevation and afebrile can mean cardiac) * Discharge teaching all manifestations go away except cardiac return to school depends on recovery School work in AM (fever often in afternoon) |
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About Hypospadias
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Opening on ventral surface (underside)
gives normal appearance facilitate voiding standing facilitate reproductive capability done 6-18 months (before child develops castration and BI anxiety) NO circumcision, male hormones given for short time prior to surgery (achieve additional penis size for surgery) |
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Assessment for hypospadias
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Abnormal urinary stream
If admitted: assess childs perception of surgery and what he calls his penis |
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Pre-op prep for hypospadias
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Use doll and put bandage and cath on penis (remind penis is still there)
avoid terms like “cut off” If giving pre-op IM med, tell just shortly before |
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Post-op hypospadias
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Check COCA urine (should be clear yellow)
Usually have cath Hematuria or cloudiness (could be unexpected bleeding or exudate) Assess visible penis (some edema ok) if 1st of 2 surgeries, penis misshapen (normal for pre-schooler to show people his penis) Teach parents: Pre-occupied with penis is normal (for child) will gradually decrease if they display a matter of fact attitude about it |
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General info re. bronchiolitis
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RSV (respiratory syncytial virus, most often cause)
very contagious *(peak incidence at 6 months)* infants who were preemies or cardiac (highest risk) May Rx w/ Ribavirin (antiviral) -given with mist under tent or mask) -pregnant nurses do not care for baby |
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Symptoms of bronchiolitis
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wheezy
nonproductive cough dyspnea irritability Resp. (60-80) nasal flaring and retractions *restlessness* 1st sign of hypoxia fine rales at end of inspiratory and early expiration |
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Signs of impending Resp. failure with bronchiolitis
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-severe inspiratory retractions
-sudden diminished or absent inspiratory breath sounds |
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Impotant to check for hydration with bronchiolitis - How?
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-weight loss
-decreased urine output -increased specific gravity -poor skin turgor -dry mucus membranes -depressed anterior fontanel -no tears with crying |
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Interventions for bronchiolitis
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Respiratory Isolation
-gown, gloves and mask for RSV High Humidity Cool Environment with O2 per order Tuck in plastic canopy securely under mattress wipe down canopy sides and back Q2 hours extra linens on mattress change clothes and linens frequently *often use micro gtt - cc/hr = gtts./min* Daily weight Promote rest HEAD OF CRIB elevated 30-40 degrees OR use infant seat |
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Symptoms of Croup Syndrome
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-severe sore throat
-drools saliva -voice muffled -leans forward while sitting up / mouth open / tongue protrusion (tripod position) -Rapidly increasing resp. stridor *rapid total airway obstruction can occur within minutes* |
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Treatment of Croup Syndrome
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-STAT upright position (possible O2 to decrease distress)
-X-ray of soft tissue of neck for Dx. -Intubation kit at bedside at ALL TIMES ******* -Direct visualization only by MD and only with resuscitation equip. ready **(can get sudden laryngospasm - complete airway obstruction) -AB given IV, then p.o. for total 7-10 days (swelling decreases after 24 hours of AB) -steroids to decrease edema |
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Symptoms of Acute Laryngotracheobronchitis (LTB): (viral croup)
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-gradual onset
-often occurs with or after URI -low grade fever -hoarseness -barking or brassy cough -gradually increasing resp. stridor -labored resp. -retractions -restlessness |
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Treatment for Acute Laryngotracheobronchitis (LTB): (viral croup)
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-Intubation equip. AT ALL TIMES******
-high humidity cool mist (direct towards face) -nebulizer (if stridor at rest) -epinephrine (decreases edema) -improvements in 10-15 min. (recur often in 2 hours) |
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Symptoms of Spasmodic (Midnight) Croup:
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-sudden onset- often at night
-paroxysmal attacks of laryngeal obstruction -Symptoms same as LTB (EXCEPT NO FEVER) -last several hours at night -may only have cough and hoarseness in am -symptoms usually recur next 1-2 nights -Laryngeal spasm may be relieved if taken out into COOL air -steamy bathroom (cool is better) |
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General info re. Leukemia
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Leukemic process in bone marrow interferes w/ production of normal red, white, and platelets.
Proliferation of immature WBC’s **Manage pain r/t disease and invasive procedures ***ALL (acute lymphocytic leukemia) -most common form of child (80%) |
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Effects of decreased RBC in leukemia
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-weakness
-pallor -fatigue -dyspnea -cardiac symptoms -Normal RBC 4.31 -Decreased H&H |
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Effects of decreased platelets in leukemia
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Thrombocytopenia (normal count 150,000 - 400,000)
-petechiae -purpura -bruising -if < 20,000 may see epistaxis and oral bleeding |
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Effects of decreased WBCs in leukemia
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(normal count 4,500 - 13,500)
-increased risk for infection -fever (also due to hypermetabolic state) |
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Effects of decreased kidney involvement in leukemia
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-uric acid increases
-x-ray shows leukemic infiltrates in kidneys -see renal failure |
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Leukemia labs
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-CBC
-Chem -peripheral blood smear |
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Diagnosis of Leukemia
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Dx. confirmed by exam of bone marrow (posterior iliac crest)**
-injection to numb area of aspirate -will feel pressure when large bore needle inserted -few seconds of pain when marrow being aspirated -Apply pressure for at least 5 minutes *******prevent bleeding -lumbar puncture may be done / CNS has been invaded by disease |
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Leading cause of death with leukemia
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Infections
-AB Tx when fever occurs -may get fungal infection |
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To prevent renal failure from elevated uric acid levels in leukemia
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-IV hydration
-urinary alkalinization -Allopurinol (uric acid is released during cell destruction / can accumulate in renal tubules) -encourage fluids with Allopurinol **Normal F&E balance prior to Tx. |
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10x more likely to occur with leukemia
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Herpes Zoster
Keep away from chicken pox and shingles** Acyclovir (antiviral) used to Tx herpes |
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For remission induction of leukemia
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Vincristine, L-Asparaginase, and Prednisone
Vincristine S/E: -abd. pain -n/v -alopecia -constipation **TOXIC: peripheral neuropathy |
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to prevent CNS disease in leukemia
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Methotrexate (intrathecally)
-no salicylates or sulfonamides (decreases action of drug) -no vitamins w/ folic acid (interfere w/ cytotoxic action of med because it is a folic acid antagonist) |
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Family support for leukemia pt
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Teach and prepare child for procedures
Prevent, Assess and Treat Infection -keep from infectious people -assess for infection (children will not show s/s ) ex. redness, drainage |
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Fever reduction in leukemia
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-tepid sponge
-cooling blankets -tylenol (no asa) -keep warm (if chilling) -change linen (perspires when temp is down) -If fever and no chilling (wear few clothes) |
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Infection prevention in leukemia
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-good hygiene
-No rectal temps -HANDWASHING -assess mucus membranes & skin, keep lips moist -If protective isolation : NO FRESH FLOWERS -Low-bacterial diet (no fresh fruits or vegetables) |
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To prevent or assess and tx hemorrhage in leukemia
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-If nose bleed (HIGH FOWLERS & Lean Forward)
-apply pressure for 10 minutes -If still bleeding : cold cloth into nostrils and on bridge of nose -If bleeding in mouth: dry teabag -handle gently -soft toothbrush or swab mouth -avoid injections **If reaction to transfusion: STOP IMMED. and keep vein open w/ NS***** |
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Assessment and Tx for pain in leukemia
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-drug therapy on regular schedule to prevent (not treat) and often give around clock
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Managing stomatitis (r/t chemo) in leukemia
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-Topical lidocaine / systemic analgesics
-bland, moist, soft diet -soft sponge toothbrush |
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Managing Hemorrhagic Cystitis (r/t chemo) in leukemia
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-irritates bladder
-liberal fluid intake -frequent voiding -admin. chemo early in day to allow for sufficient oral intake and voiding -assess for early signs of cystitis (burning on urination) *also know alopecia is a s/e |
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To minimize nutritional problems in leukemia
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-small frequent meals
-child to pick foods |
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To decrease N/V in leukemia (r/t chemo)
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-environment free of noxious odors
-avoid foods with strong odors -avoid large amounts of fat -maybe clear liquids or bland diet -cool or room temp foods (tolerate better than warm) -fresh air -antiemetics ****Stop infusion at first sign of infiltration**** |
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Discharge teaching for leukemia pt (post chemo)
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-keep child away from infectious people
-report infection STAT -no live virus vaccines for immunizations ex. (MMR) *Can’t give til 3 months after chemo |
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Bone marrow transplant for leukemia
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Protective Isolation
Immunosuppression Transplant process: Difficult for parents (2 children now in hospital at same time) |
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Post BM transplant for leukemia - nursing care:
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10-20 days required for donor marrow to engraft and begin to proliferate mature cells
during period, child has no ability to fight infections **STRICTLY FOLLOW PROTECTIVE ISOLATION TO PREVENT INFECTION** (most important aspect of care) |
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General info re. cystic fibrosis
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dysfunction of exocrine gland
thickened and tenacious secretions / occlude glandular ducts autosomal recessive trait (both parents carriers - heterozygous) 25% chance of occurring with each pregnancy |
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Respiratory tract s/s in cystic fibrosis
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-tenacious secretions of mucus glands that line resp. tract
-plug airways -repeated resp. infections (excellent media for bacteria) -At first dry hacking cough -then loose and productive |
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Cystic fibrosis effects on pancreas
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plugged pancreatic ducts ---> pancreatic fibrosis ---> decreased production pancreatic enzymes ------> disrupts digestion
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Cystic fibrosis effects on intestinal tract
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-meconium ileus
-maldigestion of foods (esp. fats) |
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Effects of lack of pancreatic enzymes in cystic fibrosis
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-stools large
-frothy -bulky (steatorrhea) -foul smelling(azotorrhea) -even if child eats large amt. / will not gain weight ****Prolapse of rectum most common complication of the GI tract in child not Tx**** |
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Cystic fibrosis effects on sweat glands
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-tastes salty
-salt frosting on skin |
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Highest priority NSG dx in cystic fibrosis
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Ineffective Airway Clearance
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to diagnose cystic fibrosis
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Sweat Test (reliable results difficult first 2 weeks) babies don’t perspire enough
After this, normal sweat range of Chloride is <40 meq/l 40-60 - suggestive of CF >60 - CF |
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In what ways can the nurse can assist with dx of cystic fibrosis?
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-when taking hx, consider CF if failure to thrive
-recurrent resp. infections -large bulky stools -ask if child eats a lot |
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Pulmonary therapy for cystic fibrosis (done to clear secretions and control infections)
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-axillary temp.
-assess adequate resp. care -monitor vs and pulse ox. -aerosol tx. 10 minutes BID (before postural drainage) can use NS or bronchodilators, mucolytics -mist tent (reduce viscosity) -Chest PT to all lobes / prophy. QID (more often w/ resp. infection) 1hr before meals stand on head “wheelbarrow” hang by knees on trapeze -bronchodilators -may give expectorants -NO COUGH SUPPRESSANTS (“aka” antitussives) |
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Dietary adjustments for cystic fibrosis
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-Diet high in Protein and CHO
-sometimes low in fat -Need 2-3 times normal caloric intake (compensate for malnutrition, chronic pulmonary infections, and growth) -have voracious app. -Salt intake increased -More salt needed in hot weather (give pretzels) |
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Re. pancreatic enzyme replacement in cystic fibrosis
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-(ex.) Pancreas, Cotazym pancreas
-facilitate utilization of nutrients -take w/ or immed. before ALL meals & snacks (don’t take if you skip a meal) -capsules can be opened and put in applesauce for infants and sm. children -give with antacids (inactivated by gastric acids) -amount of enzymes needed increase as child grows and w/ high fat content -if fat increased in diet - steatorrhea will increase (unless more enzymes given) |
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Parent/child teaching for cystic fibrosis
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-evaluate child to see if they know how to use inhaler
-ask child to show you how she will use it |
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Prognosis/outcomes for cystic fibrosis
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-pulmonary complications usual cause of death
-with increased life expect. / increase in insulin dependent DM -If pregnant / increase risk of perinatal and maternal morbidity R/T resp. problems |
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General description of bronchial asthma
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chronic inflammatory d/o associated w/ reversible, episodic airway obstruction
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Causative factors of bronchial asthma
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-allergens (grasses, molds, pollens, dust)
-irritants (tobacco smoke) -exercise -cold air -URI’s -animals -emotions -food ( chocolate, nuts, milk , dairy) -food additives ****peanuts and food dyes are highly allergenic**** |
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Pathophysiology of
acute asthma attacks: |
-bronchioles narrow, become obstructed
-air gets trapped in lungs -crackles and wheezes on expiration Then: -gases trapped in alveoli reduce ventilatory efficiency -decrease in po2 (even though child working hard to inspire enough air) Then: -hyperventilation is no longer able to compensate for hypoventilated alveoli -pco2 increases (now resp. acidosis occurs) |
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Symptoms of acute asthma attacks
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*some are continually symptomatic w/ episodes of severe airway obstruction
*some have periods of no SOB or wheezing but have chronic cough (esp. @ night) First -dry hacky cough Then: -productive cough w/ frothy, clear mucus Then: -SOB and c/o tight feeling in chest -respirations increase -expiratory phase becomes prolonged -expiratory wheezing begins -child in sitting position with shoulders hunched forward -(if severe asthma) may see growth delays and barrel chest |
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Peak Exp. Flow Meter (Three Zones):
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Green Zone:
-80-100% expected PFR (peak flow rate) : usually SYMPTOM FREE Yellow Zone: -50-80% expected PFR: asthma attack may be beginning Red Zone: -Below 50% PFR: experiencing asthma exacerbation |
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To diagnose asthma measure...
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-PEFR (peak exp. flow rate) measures max. flow of air that can be forcefully exhaled in 1 second
-measure each day (so you know usual for child) -if at any day lower, seek medical attn. (ex. today 250 but usually 500) |
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Types of meds for asthma
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-long term control preventer meds (maintains control of inflammation)
-quick relief meds (tx symptoms and exac.) -Meds via MDI : use spacer / 1 puff at a time / wait 1 minute between puffs -can use nebulizer if child too young |
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Four asthma meds
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-Corticosteroids (p.o., oral, aerosol)
long term use causes Cushing’s and growth suppression -Cromolyn sodium: (NSAID for asthma) inhibits airway narrowing after exposure to exercise or cold (NOT EFFECTIVE DURING ASTHMA ATTACK) ****Must be taken even when no symptoms**** -B-adrenergic agonists (albuterol, terbutaline) bronchodilators used to Rx ACUTE attacks and to prevent exercised induced asthma -Theophylline: Adjust dose to keep blood level of 5-15**** |
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Mgmt. of acute asthma
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-High Fowler’s position
-Administer Humidified 02 -Administer and monitor meds (use MDI w/ spacer) **spacers prevent thrush when using inhaled steroids -As condition improves -----> oral fluids (warm or room temp., cold may trigger bronchospasm) -Status asthmaticus: unrelieved bronchospasm continues despite usual Rx. -If no response : SC EPINEPHRINE |
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Long-term mgmt. of asthma
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-avoid offending agents
-protect from extreme environmental temperatures -teach child to breath through nose, NOT MOUTH -cover nose and mouth w/ scarf or cupped hand -no wool or furs -no pets with furs or feathers -fish pet is best -breathing exercises -purse lipped and diaphragmatic exercises ---> blow bubbles, blow cotton balls, pin wheel, ping pong balls, prevent a tissue from falling -support growth & development (physical activity can be beneficial if asthma can be controlled) -swimming usually well tolerated -can usually do strenuous exercise if take prophy. meds first -don’t have to avoid strenuous exercise, just have asthma under control -if symptoms occur during activity, Rx may not be adequate |
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Pathphysiology of nephrotic syndrome
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Major alteration is an increase in the permeability of the glomerular capillary wall to normal plasma proteins (esp. albumin)
See severe proteinuria (albuminuria) See decreased serum albumin |
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Symptoms of nephrotic syndrome
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-Pale
-lethargic -anorexic -irritable -decreased activity tolerance -edematous w/ ascites and weight gain -Urine dark, frothy, decreased volume, increased specific gravity -4+ protein -may be hx of recent infection |
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Edema mgmt. in nephrotic syndrome
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Monitor edema q shift: (often develops slowly)
-Often puffiness of face (esp. eyes) decreases during day -progressive weight gain, despite poor app. -daily weight -I&O -measure abdominal girth To decrease edema of eyelids: HOB elevated (gravity helps) -elevate scrotum to decrease edema |
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VS in nephrotic syndrome
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Monitor
*(most children normotensive) |
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Check all urine with nephrotic syndrome for
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-color (dark)
-amount (decreased) -Specific gravity (increased) -protein (4+ proteinuria) -frothy |
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Assess behavior & activity tolerance with nephrotic syndrome
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-initially on complete bed rest & upright (decreases tissue 02 demand)
-provide well-balanced diet : rich in protein (if child will take it) |
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Drug of choice for nephrotic syndrome
|
Prednisone
*Proteinuria should disappear in first weeks of therapy *Give steroid with milk or food |
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Infection and nephrotic syndrome
|
-Plasma protein lost in urine are immunoglobulins
-Steroid masks infection (monitor for infection) -no contact with infected people |
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To prevent skin breakdown in nephrotic syndrome
|
opposing skin surfaces should be kept clean and separated
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Discharge teaching for nephrotic syndrome
|
-relapses often occur 2-4 times/ year
-test urine for protein at least 2x/week (tells early exac.) -If relapse occurs (or child sensitive to steroids) -Rx w/ immunosuppressants (ex) Cytoxan Common s/e : -Decreased WBC -increased susceptibility to infection -cystitis from drug accumulating in bladder before excretion |
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General info about diarrhea
|
BASED ON CONSISTENCY OF STOOLS ONLY
Not amount or frequency |
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Causes of diarrhea
|
-Food intake: overfeeding, new food given, too much sugar
-GI Infection: Rotavirus -Shigella- transmitted person to person -Antibiotics: change normal flora - get overgrowth of another organism |
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Assessment for diarrhea (history)
|
-recent travel?
-behavior before and during BM (if baby has cramps - cries, flexes knees, clutches abd.) |
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Dehydration assessment for diarrhea
|
-decreased weight
-dry mucus membranes -poor skin turgor -decreased output -increased specific gravity of urine (>1.020) -absence of tears (infants don’t develop tears til after 3 months old) -elevated temp. (axillary, NOT RECTAL) -depressed fontanels if < 18 months |
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Three things to assess for with diarrhea
|
Dehydration
Metabolic acidosis Hypovolemic shock |
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Nutritional needs with diarrhea
|
-Give ORAL rehydration therapy (ORT)
-Oral rehydration solution (ORS) ex. Pedialyte -After rehydration, ORS can still be given during maintenance fluid therapy -Alternate water or breast milk (low NA fluids) -resume infant/ child’s usual diet (this will increase stools initially) -Many doctors encourage the above Rx instead of encouraging clear fluids (which have increased CHO & decreased electrolytes) -BRAT DIET (bananas ripe and mashed, rice, applesauce, and toast - dry) |
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Skin care with diarrhea
|
-change diaper as soon as soiled
-no soap on diaper area -if not rinsed well, causes skin breakdown ( MOST COMMON CAUSE ) |
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First thing to do in treatment of severe diarrhea
|
Enteric Precautions
|
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Hydration with severe diarrhea
|
-NPO for 12-48 hours to rest the GI tract if seriously ill
-Often use micro gtt. 60 gtts/cc |
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Parenteral rehydration with severe diarrhea
|
-Done in 3 phases
-Emergency or initial phase: fluids given rapidly to improve circulation and renal function. -K+ given with caution if output ok (CHECK OUTPUT FIRST) Ex. wet diapers |
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Assessing response to fluid therapy with severe diarrhea
|
-Daily Weight (MOST RELIABLE MEASURE OF FLUID LOSS OR GAIN)
-Tells effectiveness of rehydration |
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S/S of fluid overload in sever diarrhea
|
-Moist rales
-Increased BP -Distended neck veins -SOB -Marked weight gain -Decreased urine specific gravity |
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What's Myelomeningocele
|
-sac-like cyst protrusion
-often in L-S area -Neural Tube Defect -Contains meninges, spinal fluid, a portion of spinal cord w/ it’s nerves -enclosed in thin membrane (prone to tears & leakage of CSF) -Elevated alpha feto protein in pregnancy if infant has open Neural Tube Defect |
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Symptoms of Myelomeningocele
|
-flaccid paralysis of legs
-neurogenic bladder -fecal incontinence -musculoskeletal deformities -hip dislocation or subluxation -talipes varus or valgus (club foot) -dribbles urine & feces continuously -1/3 have MR |
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Spina Bifida Occulta symptoms
|
-often no symptoms
-tuft of hair or dimple |
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When does Hydrocephalus occur?
|
Occurs in 90% of L-S myelominingoceles
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Why surgical closure of Myelomeningocele is done
|
To prevent infection and trauma to sac and avoid stretching other nerve roots
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Causes of Myelomeningocele & Hydrocephalus
|
-genetic disposition
-folic acid deficiency |
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head & chest circumference check with Hydrocephalus
|
-normally head about 1 inch larger than chest
-if head size increases or is >1 inch larger than chest (may indicate hydrocephalus before other neurological signs -causes sunset eyes - eyes rotated downwards **Check for bulging Anterior fontanelle (increased ICP) -high pitched cry ******(neurological damage) |
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Characteristics of neurogenic bladder with Myelomeningocele
|
Check for bladder distention
-a neurogenic bladder becomes distended w/ retained urine -comes out in trickles because of overflow |
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Position for Myelomeningocele
|
-Prone Position *
Protecting Sac from injury is PRIORITY* -Trendelenburg (decreases csf pressure in sac) -IF MARKED HYDROCEPHALUS, ELEVATE HEAD TO REDUCE ICP Abduct thighs |
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Most important assessment with Myelomeningocele & Hydrocephalus
|
-Assess for increased ICP **(most important assessment)**
could be caused by hydrocphalus or meningitis see increased head circumference tense or bulging fontanelle (these are earliest signs of ICP) prolonged fussiness or irritability |
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Dressing for Myelomeningocele
|
apply and change moist sterile dressings to sac
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Urinary system care with Myelomeningocele & Hydrocephalus
|
-check for bladder distention
-perform regular catheterizations -prone to UTI so check odor **Teach parents frequent diaper change and scrupulous skin care -prevent pressure sores and skin breakdown |
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Care post shunt placement for Myelomeningocele & Hydrocephalus
|
-position flat or side lying on unoperated side
-abduct hips **check for increased ICP* (MOST CRITICAL) Increased head circumference bulging fontanelle poor feeding high pitched cry fussy, irritable dilated pupils -pump shunt (if ordered) -if damp area of clear fluid noted under head dressing ( check it for glucose) to see if csf. |
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General info re. poisoning
|
-highest incidence w/ 2 year olds
-first concern is for life suppport -check vs -give resp. and circulatory support as needed -find out what child ingested -NO LONGER recommend syrup of ipecac to remove the ingested poison by vomiting (increases risk of aspiration) |
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If poisoned by Noncorrosives
|
-gastric lavage
-give activated charcoal (odorless and tasteless) if given within 30 minutes of ingested poison (can bind w/ poisons that were not removed by lavage) Mix w/ water and drink through a large bore straw from dark container (looks distasteful) |
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Symptoms of poisoning by corrosives
-toilet bowl cleaner -drano -ammonia -lysol -batteries |
visible severe burns and edema of mouth, lips, tongue, and throat
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Tx for poisoning by corrosives
|
No vomiting or lavage:
-would re-expose mucus membrane to corrosive -HAVE CHILD DRINK WATER OR MILK (to remove corrosive and prevent further damage) (some suggest not using milk because it may make assessment difficult) DON’T NEUTRALIZE (causes thermal burns) Keep child calm so they do not vomit May do Esophagoscopy *First check for drooling or crying when swallows *****FIRST PRIORITY**** MAINTAIN PATENT AIRWAY |
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Rules/complications of poisoning by Hydrocarbons
-gas -kerosene -fuel oil -turpentine |
-NO vomiting or lavage
Most common complications are pneumonitis and pneumonia |
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Teaching for all poisons
|
-label all containers
-place harmful substances (incl. batteries) on high shelves or locked cabinets -use childproof caps -replace meds and poisons as soon as used -administer meds as drugs (never refer to as candy) -keep ointments away from baby during diaper change -hang plants high -special hooks that go inside of cabinets -take meds out of child’s sight -enc. parents to bend down to child eye level and survey home -have number of poison control center readily available -DO THIS TEACHING AFTER CHILD STABLE****** |
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Salicylate Poisoning
Symptoms: |
-tinnitus (mild toxicity)
ASA overdose can also cause: -hyperventilation w/ resultant resp. alkalosis -hyperpyrexia -bleeding (seldom seen w/ acute salicylate poisoning) |
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Acetaminophen Poisoning
Symptoms |
Major toxic effect is liver damage**
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Acetaminophen Poisoning Management
|
same as non corrosives
Mucomyst (antidote) give in place of activated charcoal |
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Lead Poisoning (plumbism)
Causes |
-Lead based paint (most common cause) seen in older homes
-food in lead soldered cans -drinking water from lead pipes -ingesting soil contaminated with chips or powdering with old paint -colored ink in newspapers or magazines ***Children absorb 3-5 times more lead than adults |
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Lead Poisoning (plumbism) Symptoms of CNS and PNS involvement
|
-often first see behavioral changes (irritable, aggressive, decreased interest in normal play, lethargy or hyperactivity)
-loss of newly acquired motor skills (ex) used to feed self and now can’t |
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Lead Poisoning (plumbism) Symptoms of bone marrow involvement
|
Develop anemia
Blood (serum lead levels) 10ug/dl or > is concern |
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Lead Poisoning (plumbism) TX (usually begun when levels 45 or >)
|
-Chelating agents (ex) CaEDTA, BAL (Dimercaprol), Succimer
-Often CaEDTA and BAL are given together, combination has fewer S/E and removes lead from the brain more effectively |
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Facts about CaEDTA (for Lead Poisoning)
|
-main drug used
-enables free lead to be excreted by urine 20-50 times normal rate -give deep IM or IV -Injections painful -Add procaine -Emla cream 2 1/2 hours before -encourage fluid intake -DO NOT GIVE MED IF DEHYDRATED -Main toxic effect is nephrotoxicity****** monitor renal function -check for oliguria |
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Facts about BAL (for Lead Poisoning)
|
-CANNOT BE GIVEN IF CHILD ALLERGIC TO PEANUTS
-prepared in peanut oil -NO IRON THERAPY WITH BAL |
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Complications of lead poisoning
|
Supportive care for complications:
-Encephalopathy -Anemia -Nephrotoxicity |
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Best way to prevent lead poisoning
|
-BEST WAY IS TO EDUCATE PUBLIC
Teach Parents: -Re-exposure to lead MUST be prevented |
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General info re. Tracheoesophageal Fistula
|
-Most common where proximal esophagus ends in a blind pouch & distal esophagus is attached to the trachea
-Often see maternal polyhydramnios |
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Symptoms of Tracheoesophageal Fistula
|
-constant drooling
-excessive secretions in mouth and nose (at risk for aspiration) -see 3 C’s (coughing, choking, cyanosis) esp. w/ feeding -first two occur w/ overflow, then cyanosis R/T laryngospasm (protective mechanism that prevents aspiration) -apnea may occur Note symptoms before first feeding** -If feed, see 3 C’s and return of feeding through nose and mouth -Reason Sterile water given for first feeding |
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Interventions for Tracheoesophageal Fistula
|
Prevent Aspiration (MOST IMPORTANT) & PNA
-Position on back with HOB elevated 30 degrees ( semi-fowlers) -reduces reflex of gastric secretions into trachea -enhances pooling of secretions into the bottom of the upper esophageal pouch -makes breathing easier when abdomen distended -NPO (prevents aspiration & prepares for surgery -Aspirate secretions in nose, mouth, and blind pouch -may keep blind pouch empty w/ continuous or intermittent suctioning -NEED TO DO TRACHEAL SUCTIONING WHEN YOU SEE SUBSTERNAL RETRACTIONS -Put in and drain gastrostomy tube by gravity -leave open & elevate tube above level of abdomen -put in isolette w/ high humidity (decrease viscosity of respiratory secretions) Prevent and observe for signs of infection of surgical incisions: -gastrostomy (first used to allow air to escape and then to feed) |
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First operation for for Tracheoesophageal Fistula
|
-put in gastrostomy tube and ligate distal esophagus from trachea and close distal esophagus
-perform cervical esophagostomy of proximal esophagus to drain oral secretions (esophageal pouch is brought out to the skin of the neck) need good skin care to prevent breakdown from continuous moisture -(keep clean and protect with thin layer of ointment) -pacifier -p.o. fluids may be allowed (even though they would come right out)- to encourage sucking patterns and oral stimulation |
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Post operation for Tracheoesophageal Fistula
|
Maintain adequate resp. and prevent PNA
- during surgery MD will mark how far down suction catheter can go -don’t want to reach anastomosis area -keep on back -HOB elevated 30 degrees (prevents regurgitation into esophagus) -must reposition often to allow for full lung expansion NPO for 5-7 days: -to avoid post-op vomiting -then give gastrostomy T.F. for about 2 weeks (til anastomosis healed) -then oral feedings -After T.F. given, DO NOT CLAMP TUBE (it would prevent air from escaping from stomach) -(can cause gastric distention and pressure on anastomosis) |
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What tp prepare parents for post operation for Tracheoesophageal Fistula
|
-Symptoms of esophageal stenosis (common R/T scar tissue)
-difficulty swallowing -choking -coughing w/ feedings -refusal to eat |
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General info re. Hypertropic Pyloric Stenosis (HPS)
|
-obstruction of pyloric sphincter caused by hypertrophy of circular muscle
-occurs soon after birth -Pylorus becomes 2 times the normal size -assumes size and shape of olive -channel narrows |
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Symptoms of Hypertropic Pyloric Stenosis (HPS)
|
-baby well at first
-symptoms occur 2-4 weeks old -FIRST see regurgitation -THEN non-projectile vomiting -THEN projectile vomiting -seen during or immediately after feeding -vomitus contains gastric content -mucus -maybe streaks of blood (gastritis) -NO BILE (constrictor above ampulla of vater) -BABY ALWAYS HUNGRY (little retained) -will take another feeding immediately, then vomit again -Stool decreases in frequency and amount (constipation) |
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Dehydration and starvation signs with Hypertropic Pyloric Stenosis (HPS)
|
-failed to gain or lose weight
-lethargy -poor turgor -dry mucus membranes -loss of fat pads in cheeks -sunken eyes and fontanels -no tears -rapid thready pulse -decreased output -increased specific gravity Distention of epigastrum: -peristaltic waves passing from LEFT to RIGHT -may be seen during and after feedings |
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Lab results in Hypertropic Pyloric Stenosis (HPS)
|
-Decreased: serum Na, K, Cl *normal Na 134-146
*normal K 3.9-5.0 (higher in infants) *normal Cl 97-110 -Increased Ph and Bicarb (due to vomiting which causes metabolic alkalosis) -Increased Hgb, Hct |
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Pre-Op Management for Hypertropic Pyloric Stenosis (HPS)
|
-Want to restore F&E balance and correct any dehydration ****
-If dehydrated (may have metabolic alkalosis) need to correct prior to surgery **** -Weigh daily Prevent Infection: -wash hands -no one with infection near baby -good mouth and skin care -change diapers immed. (urine concentrated if dehydrated) -change position frequently (to prevent PNA) |
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Post-Op Care for Hypertropic Pyloric Stenosis (HPS)
|
(VS, I&O & Infection plus)
Provide adequate nutrition: -often still vomit 1-2 days post-op due to persistent gastritis -IV’s until adequate p.o. -Feeding often started 4-6 hours post-op -G/W or electrolyte solutions are given frequently in small amounts -IF NO VOMITING, gradually substitute with Breast milk or formula (usually by 24 hours post-op) -Some MD’s allow breast milk to be given 4-6 hours post-op -Elevate HOB and put on RIGHT SIDE after feeding -If still fussy after feeding, give pacifier |
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General info re. Sickle Cell Anemia
|
-Autosomal recessive - 25% chance w/ each pregnancy
-hemolytic types of anemia -In U.S. primarily occurs in black people |
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What happens when Hb S is deoxygenated in sickle cell anemia?
|
-Cells that are sickled can’t pass through blood vessels and are permanently trapped
-when occlusion extensive, tissue necrosis and pain occur -(called vaso-occlusive sickle cell crisis) -Since sickled RBC’s are less able to withstand stresses of circulation and shorter life span than normal cells, chronic hemolytic anemia results |
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Symptoms of sickle cell anemia at birth
|
Symptoms not apparent at birth:
-because high levels of fetal Hb (Hb F) prevent excessive sickling -sickling not often apparent til after 4-6 months old (so no problems until this time) |
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Earliest symptoms of sickle cell anemia during infancy
|
Bone Infarctions:
-may be hand-foot syndrome (symmetrical, painful swelling of hands and feet) -Priapism- painful constant penile erection (often occurs in vaso-occlusive crisis) |
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|
Effects of sickle cell anemia on spleen
|
SPLEEN FIRST TO ENLARGE (engorged with sickle cells)
-decreased functioning of spleen -may rupture -LATER, spleen small and fibrotic R/T repeated infarctions (think this is supposed to be infections) -Spleen can no longer filter bacteria -(child susceptible to infection, esp. meningitis) |
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Three types of crisis in sickle cell anemia
|
Vaso-Occlusive Crisis:
-MOST FREQUENT & MOST PAINFUL -OFTEN PRECIPITATED BY INFECTION -sickling can slow circulation and cause renal failure Sequestration Crisis: -caused by large amount of blood being sequestered (pooled) in liver and spleen Aplastic Crisis: -occurs when viral or other infection causes decreased production of RBC’s which together with usual rapid destruction of RBC’s leads to profound anemia |
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|
Diagnostic tests for sickle cell anemia
|
-Sickledex (test done from fingerstick, results in 3 minutes)
-Hgb electrophoresis (tells if child has disease or trait) **SSA is normocytic, normochromic |
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|
Nursing mgmt. for sickle cell anemia
|
Promote tissue oxygenation
-prevent sickling and a crisis -avoid strenuous activity -enc. quiet activities -avoid cold and stress (increase need for 02) -protect child from low 02 (unpressurized planes, high altitudes, underwater swimming) Promote hydration -adequate fluid intake -may help sickling and therefore prevent crisis Prevent infection -MOST COMMON CAUSE OF CRISIS |
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During a sickle cell crisis, how to minimize energy expenditures and use of O2
|
-bedrest to minimize O2 consumption
-later when no pain, child regulates level of activity that can be tolerated -prolonged O2 not given (can depress bone marrow activity) which causes anemia -observe response to O2, (decreased pain) |
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During a sickle cell crisis, how to Promote hydration
|
-oral and IV fluids to dilute blood and reduce sickling
*MOST HELPFUL IN REVERSING CRISIS (give 2 x’s usual amount) -I&O -weigh on admission -check mucus membrane (best way to evaluate hydration)******** -CAN’T use amount or specific gravity of urine to assess hydration because of ability of kidneys to concentrate urine is impaired in sickle cell anemia -check serum electrolytes |
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During a sickle cell crisis, how to Relieve pain
|
-try to prevent pain
-give around the clock -give IV analgesics (morphine) -Heat (ex) warm packs, heating pads to painful areas (dilate vessels) -gentle handling -WANT TO KEEP PAIN < 3 ON A 1-10 SCALE |
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This med makes RBC’s slippery during a sickle cell crisis
|
Trental
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Pathophysiology of Hirschsprung's Disease (congenital aganglionic megacolon)
|
-congenital absence of nerve innervation in large intestine
-portion of distal colon lacks ganglionic cells and peristaltic waves needed to pass feces through that segment of the colon -see chronic constipation as stool and gas accumulate proximal to aganglionic segment which is narrowed -since colon above defect enlarges, condition called megacolon |
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Symptoms of Hirschsprung's Disease (congenital aganglionic megacolon)
|
CLASSIC SYMPTOM IS CONSTIPATION
In older child: -see increasingly obstinate constipation with abdominal distention (due to feces and gas) -Fecal mass can be felt in LLQ & rectum empty upon exam -When stools passed (foul smelling & pellet or ribbon-like form or may be liquid (leaks around semi-obstructed colon despite the internal sphincters failure to relax) -Children malnourished -anemic -protuberant abdomen & thin wasted extemities (weigh less than expected for age & ht.) -HYPONATREMIA may develop from malabsorption of nutrients |
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Medical/surgical management of Hirschsprung's Disease (congenital aganglionic megacolon)
|
-isotonic (normal saline) enemas
-stool softeners -low residue (fiber) diet -First usually do temporary colostomy (enables normal distal bowel to return to its original tone & size) -If double-barrel colostomy used, proximal is nearest to LEFT SIDE ******proximal excretes stool and distal excretes mucus******* -usually closed in a year |
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Teaching for Hirschsprung's Disease (congenital aganglionic megacolon)
|
-give enemas with saline (NO TAP WATER OR SSE)
-give stool softeners -give low residue (fiber) diet (keeps stools small & soft so they can be easily passed -NO BRAN, WHOLE GRAINS, RAW FRUITS & VEGETABLES, NUTS, SEEDS, POPCORN, SPICES) |
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Pre op care for Hirschsprung's Disease (congenital aganglionic megacolon)
|
-axillary temp. (rectal irritates)
-clear liquids 24-48 hours pre-op: THEN -NPO w/ NG tube& rectal tube prior to surgery |
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Post op care for Hirschsprung's Disease (congenital aganglionic megacolon)
|
-check vs THEN
-LOC -I&O (from NG tube and colostomy) -Abd. dressing -stoma (color change, edema, D/C, and bleeding) -keep diaper below abdominal dressing (so urine doesn’t contaminate) -HANDWASHING -Antibiotics tx if needed Pain meds: -before dressing change or other painful procedures -if need of frequent dressing change, use MONTGOMERY STRAPS (prevents skin irritation) |
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Outcome of Hirschsprung's Disease (congenital aganglionic megacolon)
|
-most children achieve fecal continence
-toilet training may be delayed because of intermittent diarrhea, trauma to that area, and psychological associations |
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Nsg mgmt of Cleft Lip and Palate
|
-Nurse should completely accept child
-point out all normal attributes -show before and after surgery pictures of infants who had similar malformations |
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To maintain nutrition and prevent aspiration in Cleft Lip and Palate
|
-soft nipple w/ slightly enlarged openings
-nursettes or soft lamb’s nipples -Newer “gravity flow” nipples attached to a squeezable plastic bottle (puts formula into mouth like a bulb syringe) -burp frequently -feed upright |
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Paretnt education for a child with Cleft Lip and Palate
|
-prepare baby for care required after surgery
-(ex.) cleft lip - lie on side or back w/ head elevated -(ex.) cleft palate - lie on side or abdomen -use elbow or wrist restraints periodically beforehand so baby will be used to post-op |
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|
Surgical mgmt. of Cleft Lip and Palate
|
Cleft Lip:
-repair at 6-12 weeks of age If cleft lip and palate: -repair palate after lip well healed (at 12-18 months) -wait longer if want to take advantage of palatal changes that occur with growth -done after the teeth appear to prevent damage to tooth buds BUT ******before child learns to speak (so he doesn’t learn faculty speech habits)***** |
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Pre-op care for Cleft Lip and Palate
|
-assess feeding techniques to determine changes that will be needed post-op
-Incision secured (after surgery) w/ adhesive butterfly or Logan bar (arched wire bow over incision attached to both cheeks w/ strips of adhesive) -prevent tension on suture line (esp. crying) |
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Post op care for cleft lip
|
-humidification
-pain meds regularly or mild sedative (to prevent crying) -restrain arms (release Q2hours for ROM) elbow or wrist or wrap baby -Feed on demand -feed with rubber tipped medicine dropper or BRECK feeder -CLEAR LIQUIDS, THEN FORMULA OR BREAST MILK -NO BOTTLE OR PACIFIER -POSITION ON BACK IN INFANT SEAT AFTER FEEDING -USE ROLLING MOTION ALONG SUTURE LINE - NOT ACROSS - NEVER PUT ON ABDOMEN - only back or side lying on opposite side of repair (can damage suture line) |
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Post op care for cleft palatte
|
-Check for bleeding (frequent swallowing, restless, hematemesis, increased pulse)
-POSITION ON ABDOMEN OR SIDE (promote drainage from mouth) -prevent strain on suture line during feedings rubber tipped dropper firm plastic cup side of large wide bowl spoon can’t go in mouth -no utensils in mouth -no straw or pacifier -no sucking -for irrigation, have child in sitting position, head tilted forward (so won’t aspirate) -elbow restraints for about 3 weeks |
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Parent teaching for Cleft Lip and Palate
|
-have more frequent resp. infections and otitis media w/ loss of hearing
-Rx otitis media Immediately -malpositioned teeth and dental decay may occur -some degree of impaired speech -often needs years of medical, surgical, dental, and speech therapy |
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Occurrences of Congenital Dysplasia of the Hip
|
-heredity and culture (seen in more cultures that swaddle more) ex. native americans
-disorder unknown to cultures who carry babies on mom’s backs or hips -widely abducted straddle position |
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Assessment for Congenital Dysplasia of the Hip
|
-check for asymmetrical skin folds on medial aspects of thighs and in gluteal area
-may see extra or deeper folds on affected side if dysplasia -should abduct to 90 degrees -if only able to abduct 60-70 degrees or less - limited abduction (abnormal) -shortened limb on affected side (Galeazzi sign) -Hip joint evaluated to determine if head of femur can be displaced from acetabulum when abducting hips THEN -returned no normal position -if dislocation present, may have clunking feeling (or clicking heard) -Called positive Ortolani’s maneuver -TEST MOST EFFECTIVE UP TO AGE 3 MONTHS Trendelenburg’s sign: -when toddler stands on affected leg the pelvis on the unaffected side tilts downward INSTEAD of upward |
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Medical Management for Congenital Dysplasia of the Hip
Newborn to 6 months: |
-usually conservative Rx results in normal hip by time child walks
-legs are gently flexed -externally rotated -held in abduction for about 6 weeks -Can use: splint brace Pavlik harness -NO LONGER recommend use of double or triple diapers (promotes hip extension) |
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Medical Management for Congenital Dysplasia of the Hip
6 to 18 Months: |
-If newly and Dx dislocatable & unrelocatable hip:
placed in SKIN TRACTION Then: hip reduced and SPICA cast applied -change cast about every 6 weeks (young children grow rapidly) -If skeletal traction used: **pin care is aimed at preventing osteomyelitis** |
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Nursing Management of child with Congenital Dysplasia of the Hip
|
Maintain correct position:
-teach parents how to keep hips abducted if device removed for skin assessment or bath -when changing diaper: raise infants hips by placing one hand under buttocks don’t raise buttocks by pulling on legs clothing under splint prevents irritation -NO POWDER OR LOTION UNDER |
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Cast care for child with Congenital Dysplasia of the Hip
|
-CMSTP
-when cast wet (handle w/ palms, NOT fingers) -check tightness of cast - insert finger -respiratory rate & depth -color -don’t give children small objects that they may put under cast -Check for reddened areas on the skin around cast edges -Check for small signs of infection: fever, odor from cast, hot spots -monitor for pneumonia: (R/T decreased activity) -spica cast abduction stabilizer bar used to maintain proper degree of abduction -NEVER use handle for lifting or turning -to help dry quicker, LEAVE OPEN TO AIR -Never try to dry w/ heater (stays wet underneath) -A BLOW DRYER ON COOL CAN BE USED TO RELIEVE ITCHING UNDER CAST |
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General info re. Congenital Clubfoot
|
Skeletal deformity of ankle and foot
Foot is pointed downward and inward |
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|
Assessment for Congenital Clubfoot
|
Differentiate clubfoot from intrauterine positional deformity
Positional deformity is only muscular / can be passively manipulated past midline Clubfoot CANNOT |
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Treatment for Congenital Clubfoot
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-Treatment ASAP after birth
-even in newborn nursery - gentle passive foot exercises -Correct deformity by applying series of casts until marked over correction is acheived -casts are applied when child is just a few days old because ligaments are more supple now -casts need to be changed frequently -often casts replaced Q 1-2 weeks for about 6 weeks -DENIS BROWNE SPLINT may be used instead of cast or after overcorrection by casts -helps maintain foot in desired position -ANGLE OF SHOES ON BAR SHOULD NOT BE REPOSITIONED -if shoes become loose , can be tightened against the bar -check skin of feet for reddened areas -NEED TO REMOVE TABLECLOTHS (childproof) -Ask Parents to “show you” how to apply brace...etc. |
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General info re. Iron Deficiency Anemia
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-Most prevalent nutritional disorder in U.S.
-Esp. age 6-24 months and adolescence when do not get enough iron in diet to meet growth demands -To prevent iron deficiency anemia: -introduce solids a 5-6 months (prenatal iron stores used up by this time) -do not allow toddler excessive milk intake / decreases intake of solid foods w/ iron |
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Pathophysiology of Iron Deficiency Anemia
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-Iron needed for production of Hgb
-as Hgb decreases, newly formed RBC’s become smaller (microcytic) -less filled w/ Hgb and pale (hypochromic) -Milk not perfect food “low in iron” (teach parents) -give iron fortified foods -iron fortified cereals, eggs, meat, green veggies, raisins -give these before offering milk |
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Assessment of Iron Deficiency Anemia
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-See waxy pallor, irritable, listless, anorexic, maybe constipation
-Assess for cardiac decompensation: heart works faster and harder may enlarge and have systolic murmur -Check for signs of infection: CHILDREN W/ ANEMIA : PRONE TO INFECTIONS -Assess G & D: may be delayed: if anemic, poor muscle development and reluctant to physically explore -Check Weight: may be overweight from excessive milk intake (“milk baby”) Obese and pale w/ poor muscle development may be underweight R/T anorexia may have PICA -Diet History: usually hx of large milk intake |
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Iron Deficiency Anemia Lab Results:
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Decreased
Hgb (<11) Hct (<33) MCV, MCH, MCHC serum iron |
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Diet for baby with iron deficiency anemia
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-iron fortified formula or cereal for all infants not breastfed
-1/2 iron in BM absorbed |
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Re. tissue oxygen demand in iron deficiency anemia
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-easily fatigued
-assess activity tolerance -provide for quiet play |
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Re cardiac function in iron deficiency anemia
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REPORT TACHYCARDIA or TACHYPNEA IMMEDIATELY
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To prevent or decrease emotional stress in iron deficiency anemia
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-let parents stay and give cares
-explain to parent’s, child’s need to conserve energy -anemia causes CNS effects of tissue hypoxia: -irritability -fussiness -short attention span -low frustration tolerance -headache -fatigue |
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Infection prevention in iron deficiency anemia
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-prone because of lowered resistance
-assign to room w/ UNINFECTED CHILD |
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Rules for ferrous sulfate administration
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-Administer ferrous sulfate orally in 2 divided doses daily:
-Give between meals -Give with Vitamin C -Large milk intake decreases absorption of iron -Brush teeth after taking -expect green tarry stools -monitor COCA -If emesis, or other GI symptoms : NOTIFY MD (he will increase dose and order it w/ meals) -7 days after iron started, an increase in Reticulocyte count indicates that RBC proliferation is correcting the anemia |
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Physical Responses to Congenital Heart Defects (CHD)
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-Murmurs
-Decreased exercise tolerance and dyspnea -Increased pulse and respirations -Recurrent respiratory infections -Cyanosis and polycythemia Tissue Hypoxia: -metabolic acidosis -clubbing and cyanosis of fingers -Assume certain positions: ( try to compensate for tissue hypoxia) by occluding femoral veins: -knee chest position -squatting -squatting reduces return of low oxygenated blood to heart -Growth Retardation -Cardiac Failure: -CHF RESULTS ( Digoxin drug most often used to Rx CHF) |
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Cardiac Catheterization type most used for children
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R- heart cath. is used most for children (go through femoral vein, into R atrium)
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Nursing Care Before Cardiac Cath.:
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-pressure or pushing feeling from cath.
-when dye put in, may feel warm -lights turned off, pictures taken -lasts from 2 to several hours (nurse can bring short stories to read) |
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Nursing Care After Cardiac Cath.:
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-Check color and VS Q15 minutes
-Check incision and dsg. (for bleeding or hematoma) **if bleeding at site, direct pressure for several minutes and REPORT IMMED. *** -THIS IS CRITICAL ASSESSMENT / Bleeding -Check equality and symmetry or pulses DISTAL to site -Check CMSTP and capillary refill -keep child as quiet as possible -in bed for 6-8 hours** -Keep arm or leg as straight as possible for 6-8 hours -Keep insertion site clean and dry |
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Discharge Instructions after Cardiac Cath.:
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-No tub baths
-no strenuous activities -no return to school for at least 3 days |
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In CHD, Care after episodes of cyanosis and dyspnea (ex) after overexertion:
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-Place on Abdomen or Side in knee chest position (children learn to squat)
-Loosen any restrictive clothing |
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To promote Rest and Comfort with CHD
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-Don’t let child use more energy than body’s ability to oxygenate blood
-prevent crying AMAP (plan ahead to meet needs, ex: feedings) -Often give pacifier to decrease crying (decreasing O2 needs) -Feed slowly and burp frequently |
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Parent teaching for children with CHD
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-Prevent Resp. infections
-avoid people with infections -If infection develops, Rx immed. -Prophylactic AB for minor surgeries |
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Challenges of Family Relationships with CHD child
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-Parents often question their parenting abilities because child never seems completely satisfied
-Child often has difficulty dealing with frustrating situations because he has few opportunities to do this (usually spoiled) |
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General info. re. scoliosis
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-lateral curvature of spine
-occurs more frequently in girls -usually Dx. in adolescence during period of rapid growth (age 13-15) |
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Symptoms of scoliosis
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-forward thrusting of head
-Asymmetrical rib cage -Nipples, shoulders, and hips will not be aligned horizontally - one will be higher -Scoliosis can be most easily detected if child is told to bend forward at the waist with head and arms hanging freely - will see asymmetry of flank or scapula |
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Re. Bracing in child with scoliosis
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-curving of 20-45 degrees can be held in place by brace
-wear 23 hours/ day -frequent adjustments of brace by MD (3 x’s / month) -Brace worn until spine is mature enough to support body weight without reverting to scoliosis -Brace is worn until about 6 months after physical maturity -BRACES WORN OVER SHIRT OR STOCKINETTE TO PREVENT SKIN BREAKDOWN AND ABSORB PERSPIRATION |
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Purpose of exercise for scoliosis
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strengthen & prevent atrophy of the muscles of the torso
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Surgical intervention for scoliosis
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-Harrington Rod : metal rod functions like jacket
-bone is taken from iliac crest and placed along scoliotic curve -(joins w/ vertebrae - fusion) -POST-OP CHILD LOG ROLLED TO PREVENT SPINAL MOTION AND A MOLDED PLASTIC JACKET IS USED TO STABILIZE SPINE UNTIL FUSION SOLID |
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Teaching for child with scoliosis
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-teach to remove brace only for bath and exercise
-exercise to prevent atrophy of spinal and abdominal muscles -stretches should be slow and sustained -SWIMMING MOST THERAPEUTIC (strengthens back muscles & encourages deep breathing) |
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Post op care for scoliosis
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-In ICU - PRIORITY RESPIRATORY FUNCTION****
-Log rolled when turning -Monitor VS, wound, and neuro status of extremities -CMSTP, paralysis -----> report problems IMMED. -Check Urine Output (UO) R/T extensive blood loss during surgery -Give opioids on regular schedule IV or epidural, maybe PCA (pain) |
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General info re. Tonsillectomy / Adenoidectomy
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-only indicated for massive hypertrophy (causing difficulty eating or extreme breathing discomfort)
-if adenoids enlarged / drainage from eustachian tubes blocked -otitis media is common -removal of adenoids if child has recurrent otitis media |
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Symptoms that may indicate a Tonsillectomy / Adenoidectomy is necessary
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-breathes out of mouth a lot
-breath odor offensive -Check labs *****(bleeding and clotting time and prothrombin time)**** -check for loose teeth in school age children ***** |
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Pre op teaching for Tonsillectomy / Adenoidectomy
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Teach what to expect post-op:
-position on abdomen or side lying -drink non-citrus juices from medicine cup and pretend throat is sore |
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Assessment for hemorrhage for Tonsillectomy / Adenoidectomy
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Check for Hemorrhage:
Most obvious EARLY SIGNS: -frequent swallowing -trickling of blood from site - check VS : esp. pulse increase (above 120 or any increase from norm) -check w/ flashlight (if bright red or drooling bright red blood ) NOTIFY MD -assess for restlessness -pallor -frequent clearing of throat -vomiting bright red blood (Normal to spit up dark brown blood) -IF VOMITS BRIGHT RED BLOOD “FIRST” TURN ON SIDE : THEN CALL MD |
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Post op care for for Tonsillectomy / Adenoidectomy
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Position on abdomen or side : (promote drainage and prevent aspiration)
Offer cool liquids when awake: -Large amounts -large gulps (helps pain) -no red or brown colored liquids -give popsicles -diluted fruit juices -No straws -no gargling |
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Pain mgmt. post op Tonsillectomy / Adenoidectomy
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-usually significant pain first 24 hours
-pain meds regular intervals -local anesthetics may be used (ex. tetracaine lollipops) |
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Home care post op Tonsillectomy / Adenoidectomy
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-Encourage soft foods: No firm foods for 2 weeks
-No forceful coughing or throat clearing or gargling -Mild analgesics PRN- : Tylenol (NO ASA) -behavioral changes best way to tell if pain Mouth Odor: may have a few days Tell small amount of bright red blood may occur 5-10 days post-op from scab being shed. CALL MD IF > 1 TSP.******* Regular activity can usually be resumed in 1-2 weeks |
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Post op Tonsillectomy / Adenoidectomy - report immediately:
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-BRIGHT RED BLEEDING
-FREQUENT SWALLOWING -VOMITING BRIGHT RED BLOOD -TEMP. ABOVE 100 -PERSISTENT COUGH |
