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FINAL EXAM REVIEW PATTY SEVERT, MSN, RN MUSCULOSKELETAL, RESPIRATORY, IMMUNIZATIONS/ID, CHILD ABUSE, GI, ENDOCRINE RESPIRATORY • What is the respiratory pattern like in a newborn? IRREGULAR • Pauses are normal in a newborn. • True apnea is when the pause is 20 seconds or > • Normal infant RR rate is 30-55 bpm CROUP • Caused by virus or bacteria • What kind of cough does croup produce? SEAL BARK COUGH! HOW CAN CROUP BE MANAGED AT HOME? 1. KEEP CHILD CALM 2. COOL MIST VAPORIZER 3. SIT IN BATHROOM WITH CHILD & TURN ON HOT WATER IN SHOWER. LET THE CHILD BREATHE IN THE STEAM FOR 10-15 MIN. 4. OPEN FREEZER DOOR AND LET CHILD BREATHE IN COOL, MOIST AIR 5. TAKE CHILD OUT INTO COOL NIGHT AIR. 6. KEEP THEM HYDRATED. WHY IS A COOL MIST VAPORIZER/HUMDIFIER RECOMMENDED AT HOME VERSUS STEAM VAPORIZERS? THEY ARE SAFER! • Children can get burned on the steam vaporizers d/t the heat it takes to generate the steam and the hot water. WHEN A CHILD IS IN RESPIRATORY DISTRESS, WHAT POSITION MIGHT YOU FIND HIM/HER IN? TRIPOD POSITION • child sits up, leans forward w/jaw thrust in sniffing position; refuses to lie down CYSTIC FIBROSIS • What causes this disease? • What is the pathophysiology? AUTOSOMAL RECESSIVE TRAIT • EXOCRINE GLAND DYSFUNCTION WITH MULTI-SYSTEM INVOLVEMENT • PULMONARY • GI • PANCREAS • BILIARY • SWEAT & SALIVARY GLANDS • REPRODUCTIVE GLANDS PATHOPHYSIOLOGY OF CF • Primary defect • Faulty transport of chloride in and out of cells • Increased viscosity of mucous secretions • Results in mechanical obstruction HOW IS CF TREATED IN THE GI SYSTEM? • High calorie/high protein diet • Pancreatic enzymes with every meal and snack to aid in digestion • Fat soluble vitamins – A, D, E, K WHAT IS THE RESPIRATORY MANAGEMENT IN CF? • Focus on infection prevention • Chest physiotherapy to break up mucus WHAT IS THE COURSE OF TREATMENT FOR A CF PATIENT HOSPITALIZED FOR A RESPIRATORY INFECTION? • Multiple, prolonged course of antbx • Inhaled, PO, IV • Aggressive respiratory treatment: • Dornase alpha - aerosol • Loosens, liquefies, thins secretions • Bronchodilators - aerosol • Chest physiotherapy – usually every 4 hours • Oxygen therapy • Nutrition key in healing • High protein/high calorie diet • Pancreatic enzymes with every meal and snack • Fat soluble vitamins – A, D, E, K ASTHMA • What is asthma? • What are the 3 characteristics? • Chronic inflammatory airway d/o • 1. Airway obstruction • 2. Bronchial hyperresponsiveness • 3. Inflammation HOW IS ASTHMA TREATED? 1ST – HELP IDENTIFY THE TRIGGER • Limit exposure to triggers • Quick relief medications: • Bronchodilators – short-acting beta agonists • Anticholinergics • Corticosteroids • Long-term control medications • • • • • Long-acting beta 2 agonists (salmeterol) Inhaled corticosteroids Leukotriene modifiers (montelukast) Mast-cell stabilizers (cromolyn sodium) Monoclonal antibodies (amalizumab) WHAT ARE SOME SIDE-EFFECTS OF THESE MEDICATIONS? • Short-acting bronchodilator? • Anticholinergics? • Short-acting bronchodilator – albuterol – tremors, tachycardia, nervousness • Anticholinergics – dry mouth GASTROINTESTINAL • What is the gold standard for diagnosing gastroesophageal reflux disease – GERD? ESOPHAGEAL PH MONITORING HOW IS GERD TREATED? • Conservative Therapy • Positioning • HOB 30; NO CARSEATS (increases intrabominal pressure and complicates GERD • Feeds • Thickened • Enfamil AR • Fats, spice, citrus – if older baby, child OR breastfeeding mom • Handling of infant – no playing or rocking for at least 30” after feed • Weight control – monitor for wt gain and growth and development • Pharmacologic Management • Histamine receptor antagonists • amount of acid in gastric contents • Zantac, Pepcid • Proton pump inhibitors (PPI) • Esomeprazole magnesium (Nexium) • Lanzoprazole (Prevacid) • Omeprazole (Prilosec) WHAT GI D/O HAS AN OLIVE MASS THAT CAN BE PALPATED OR SEEN ON XRAY? PYLORIC STENOSIS WHAT ARE OTHER CLINICAL MANIFESTATIONS OF PYLORIC STENOSIS? • Non-bilious, projectile • Usually immediately after feeds or within 30 minutes. • Peristalsis • Infrequent BM • Baby is irritable, hungry, not gaining weight WHAT IS THE THERAPEUTIC MANAGEMENT FOR PYLORIC STENOSIS? SURGERY! PYLOROMYOTOMY WHY ARE WE CONCERNED ABOUT DIARRHEA IN KIDS? DEHYDRATION WHAT IS THE PREFERRED TREATMENT FOR DIARRHEA/DEHYDRATION? • Rehydration • Oral preferred • IV may be needed in addition to oral • Pedialyte or other electrolyte replacement fluid • Smaller amounts of child’s normal diet • Formula • Finger foods • Etc. DEHYDRATION CAN ALSO BE CAUSED BY FREQUENT VOMITING. • If a friend asks you what to do about her child that is running a temperature and “…not able to keep anything down,” what would you suggest? • Should the child be taken to the doctor? ER? Urgent care? • Or, are there things that can be done at home? INITIALLY, THE CHILD SHOULD BE TREATED AT HOME • Encourage your friend to offer sips of clear fluids to the child frequently – small amounts • Teach your friend signs of dehydration • Encourage if this does not get better and signs of dehydration are appearing, then seek medical attention. WHAT IS HIRSCHSPRUNG’S DISEASE? • What is the therapeutic management for this? CONGENITAL AGANGLIONIC MEGACOLON • Lack of ganglion cells in a portion of the bowel • Tx – Pull-through procedure • If at least 10 kg • Aganglionic bowel is removed • Next section of normal bowel pulled down to anus • Under 10 kg – temporary colostomy until pull-through can be done. MUSCULOSKELETAL • What are the signs and symptoms of scoliosis? • Hx of poorly fitting skirts/pants • S or C shaped spine • Visuaized when bending over at the waist • Asymmetry of shoulders, scapula, ribs, flank and/or hips DOES SCOLIOSIS PRESENT WITH PAIN? NO – NOT USALLY! • Pain only comes if a curvature of 40% or > • some compensatory problems may occur such as hip and back pain DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) • Abnormal development of hip structures • What are the symptoms of DDH? Limited abduction of affected hip • Asymmetry of gluteal and thigh fat folds • Telescoping/pistoning of thigh • Older child: • Walks with significant limp • Waddling gait (bilateral) • Marked Lordosis (bilateral) HOW IS DDH MANAGED? • Pavlik harness – newborn to 6 mo • 6mo – 18mo • Skin traction • Closed reduction surgery • Spica cast • Older child • Open or closed reduction • Spica cast • Bracing WHAT EDUCATION MUST BE GIVEN TO PARENTS OF A CHILD WITH A PAVLIK HARNESS? • Wear continuously till hip proved stable (3-5mo); can take of only for baths •Placed at healthcare facility; instructions given for maintaining position; rechecks scheduled to ensure proper fit, maintenance of hip position and skin condition WHAT SHOULD BE DONE 1ST BEFORE ANY EDUCATION CAN BE GIVEN TO A PATIENT OR FAMILY? • Assess learner’s preferred learning methods • Assess learner’s readiness • Assess what knowledge learner already has WHAT IS A MAJOR COMPLICATION CONCERN FOR FRACTURES? COMPARTMENT SYNDROME • What is comparment syndrome? • MEDICAL EMERGENCY • Increased pressure in a limited space such as the soft tissue of an extremity • Compresses vessels & nerves & causes tissue ischemia • What can alert the nurse to the development of compartment syndrome? 6 p’s! • Increased pain unrelieved with medication • Paresthesia or numbness (tingling, burning) • Pallor (pale, gray or white skin) • Pressure (skin tight; cast appears tight) • Paralysis (weakness or inability to move extremity) • Pulselessness (weak or absent) • Also prolonged capillary refill CLUB FOOT AKA TALIPES EQUINOVARUS • What is club foot? • Congenital malformation of ankle and foot • What causes it? • Positional - d/t intrauterine crowding • Syndromes • Congenital - idiopathic HOW IS CLUBFOOT TREATED? • Stretching and manipulation exercises • Serial casting: long leg casts changed q 1-2 weeks for 8-12 weeks • Surgery 3-12 months last resort ENDOCRINE • What are key educational topics for newly diagnosed Type 1 diabetic and their families? • INSULIN ADMINISTRATION • Glucose monitoring • Dietary changes WHAT SHOULD BE TAUGHT ABOUT INSULIN ADMINISTRATION? • Rotate sites • Inject short-acting prior to longacting insulin • Upon admission - Begin planning to teach parent/child demonstration of injections and allow practice time to learn and to rotate sites • Signs and sx of hypo and hyperglycemia HYPOGLYCEMIA • What symptoms are displayed? • Pale, faint, weak • Diaphoresis • Rapid pulse • Irritability; sleepy • Tremors WHAT ARE THE SX OF HYPERGLYCEMIA • Extreme thirst • Vomiting • Abdominal pain • Deep, rapid respirations • Flushed • Urine + glucose & ketones TURNER SYNDROME • What is this d/o? • Most common sex chromosome abnormality in females • Missing or abnormal x chromosome • S/S: short stature, undeveloped ovaries, short web neck, amenorrhea, infertility, delayed puberty HOW IS TURNER’S SYNDROME TREATED? MONITOR GROWTH, ESTROGEN PROGESTERONE HORMONES WHAT IS KLEINFELTER SYNDROME • 47xxy chromosome d/o • Single most common cause of hypogonadism and infertility in males HOW IS IT TREATED? Testosterone replacement PRECOCIOUS PUBERTY • What is it? • Secondary sex characteristics before age 8 in girls; before age 9 in boys WHAT IS AN IMPORTANT EDUCATIONAL TOPIC? • Treat the child according to the chronological age • i.e., dress them like an 8 year old, not a 13 y.o. HYPOPITUITARISM • What is this d/o? • Growth hormone deficiency • How is it treated? SQ INJECTIONS OF GROWTH HORMONE IMMUNIZATIONS/INFECTIOUS DISEASE • What immunizations should a nurse expect to give to a 2 month old infant? • What do these immunizations protect against? • 2 month immunizations: • Hep B, Hib, PCV, IPV, DTaP, RV • Protects against: • Hepatitis B, H. influenzae, pneumococcal pneumonia, diptheria, tetanus, pertussis, polio, and rotavirus WHAT IMMUNIZATIONS ARE NOT GIVEN UNTIL 12 MONTHS? • MMR • Varicella WHAT ARE THE MOST COMMON SIDE EFFECTS OF IMMUNIZATIONS? LOCAL: Pain Erythema Swelling Induration SYSTEMIC: Fever Fussiness/irritability Malaise Anorexia Rash Arthralgia Adolescents: Syncope Vasovagal reaction within 15 min • Allergic reaction: • • • • Wheal Urticaria Petechiae Anaphylaxis WHAT NEEDS TO BE DOCUMENTED AFTER GIVING IMMUNIZATIONS? Date (month, day, year) Vaccine given Manufacture, lot #, expiration date Route Site (specific) Response Name, address, title of health-care provider VIS given & parental consent VAERS (Vaccine Adverse Event Reporting System) • Tracking • • • • • • • • • WHAT IS CONSIDERED CHILD MALTREATMENT OR ABUSE? • Physical abuse or neglect • Emotional abuse or neglect • Sexual abuse WHAT ARE SOME CHARACTERISTICS OFTEN SEEN IN AN ABUSED CHILD? • Temperament – different than parents • Additional physical needs-ill or disabled • Activity level • Degree of sensitivity to parental needs • Does the child recognize when the parent is stressed, sad, frustrated, etc? WHAT ARE THE CHARACTERISTICS OF PARENTS THAT ABUSE? • Survivors are 6 times more likely to abuse • Trouble controlling aggression, freely express violence • Socially isolated • Children of teens more at risk • Parents have low self-esteem CHILD ABUSE • What are some of the red flags that may alert you to the possibility of an abuse situation in a child? • Injury does not match the developmental stage/age of the child • Conflicting stories between caregivers • Injury inconsistent with history • Child inappropriately dressed for the season (ex: long sleeves in the summer) • Delay in seeking treatment WHAT DOES A SEXUAL ABUSER RELY ON? SECRECY!