Pediatrics Exam 2 Study Guide PDF

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This document includes respiratory, cardiovascular, nursing interventions, and neurological function, eyes and ears, and medication calculation...

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Peds Exam - 2 Study Guide

Respiratory System 1. Anatomy and Physiology of the Child’s Nose and Throat a. Nose i. Newborns have  very small nasal passages, making them more prone to obstruction ii. Infants are  obligate nose breathers; they cannot open their mouths to breathe iii. They produce very little mucus → more susceptible to infections b. Throat i.  Infant’s tongues relative to the oropharynx are larger → can lead to airway obstruction ii. Children have enlarged tonsillar and adenoid tissue → can lead to airway obstruction 2. Lower Respiratory Structures a. Bifurcation of trachea i. Occurs at the level of the third thoracic vertebra in children (compared to the six in adults ii. This is important when suctioning or intubating children and assessing risk for aspiration ` b. The bronchi and  bronchioles of  infants and children are narrower in diameter than the adult’s → increased risk of lower airway obstruction c. Smaller numbers of alveoli   i. Higher  risk of hypoxemia 3. Inspection and Observation of the Respiratory System a. Color i. Palor ii. Cyanosis iii. Acrocyanosis b. Rate and depth of respirations i. Tachypnea c. Nose and oral cavity i. Nasal flaring d. Respiratory effort i. Dyspnea e. Presence of retractions f. Anxiety and restlessness g. Clubbing h. Hydration status 4. Adventitious Breath Sounds a. Wheezing

i. High-pitched sound on inspiration or expiration ii.May occur with obstruction in lower trachea or bronchioles iii.May occur in asthma or viral infections iv. May be associated with a variety of lower respiratory disorders (asthma, bronchiolitis, and cystic fibrosis) b. Rales i. Crackling sounds heard when alveoli become fluid filled ii. May occur with pneumonia 5. Diagnosis and Monitoring of Respiratory Disease a. Pulse Oximetry i. Is a useful tool for determining the extent of hypoxia ii. Can be used by the nurse for continuous/ intermittent monitoring b. Pulmonary function testing i. Measures respiratory flow and lung volumes and is indicated for asthma, cystic fibrosis, and chronic lung c. Peak expiratory flow i. Testing is used to monitor the adequacy of asthma control d. Chest radiographs i. Can show hyperinflation, atelectasis, pneumonia, foreign bodies, pleural effusion, and abnormal heart or lung size 6. Laboratory and Diagnostic Tests ordered for Respiratory Disorders a. Chest radiograph i. Might reveal hyperinflation and patchy areas of atelectasis of infiltration b. Blood gases i. Might show CO2 retention and hypoxemia c. Nasal-pharyngeal washings i. (+) identification of RSV or other viral illness via enzyme-linked immunosorbent assay (ELISA) or Immunofluorescent antibody (IFA) testing d. Rapid strep testing i. Via throat swab culture 7. Laboratory and Diagnostic Tests Ordered for Pneumonia a.Pulse oximetry i. oxygen saturation might be decreased significantly or WNL b. Chest x-ray i. varies according to child age and causative agent c. Sputum culture i. May be useful in determining causative bacteria in older children d. WBC count i. Might be elevated with bacterial pneumonia 8. Laboratory and Diagnostic Tests Ordered for Cystic Fibrosis a. Sweat chloride test i. Considered suspicious if: - Level of chloride in collected sweat is above 50 mEq/L - Diagnostic if the level is above 60 mEq/L

9. Common Medical Treatments for Respiratory Disorders a. Oxygen b. High humidity i. Oxygen should be humidified to prevent drying of secretions c. Mucolytic agents d. Suctioning, Saline gargles or lavage i. Very effective at maintaining airway patency, especially in infants e. Chest physiotherapy and postural drainage f. Chest tubes g. Bronchoscopy 10. Oxygen Delivery Devices a. Nasal cannula i. Can be used to deliver up to 4 liters per  minute ii. Provides an additional 4% O2 per 1 L of oxygen flow (ex: 1 L will deliver fjfjfjfjjfjfjfjfjfjfjj25% oxygen b. Simple mask i. Can be used to deliver a flow rate of 8 liters per  minute ii. provides about 40% oxygen c. Venturi mask i. Can be used to deliver a specific percentage of oxygen. From 24% to 50% d. Oxygen Hood i. Requires a liter flow of 10 to 15 liters per  minute e. Non re-breather mask i. Provides 80-100% oxygen 11. Alternatives to Traditional Mechanical Ventilation a. High Frequency Oscillators i. Provide respiratory rates up to 1200 bpm with low tidal volume b Nitric Oxide inhalation (INO) i. Inhaled nitric oxide gas ii. Causes vasodilation to increase blood flow to alveoli c. Perfluorocarbon liquid i. Acts like a surfactant ii. Improves gas exchange d. Extracorporeal membrane oxygenation (ECMO) i. Blood is removed from the body, warmed, and oxygenated and returned to the njnjnnjnjnjjnnjnjpatient via pump ↳ Risk of bleeding is great 12. General Aspects - Acute infection of the respiratory tract is the most common cause of illness in infancy/ childhood a. Predisposing Factors i. Close contact with other children ii. Frequent hand to mouth activity iii. Lack of hygiene awareness iv. Decreased resistance to certain viruses/bacteria

b. Upper Respiratory tract i. Oronasopharynx ii. Pharynx iii. Larynx iv. Trachea c. Lower respiratory tract i. Bronchi ii. Bronchioles iii. Alveoli 13. Risk Factors for Respiratory Disorders a. Prematurity i. Chronic lung disease is seen a lot in premature patients and can cause an jnjnjnjnnjnjnjnjjj i ncreased risk for respiratory ailments later in childhood, long after infancy. b. Developmental disorders (cerebral palsy) c. Passive exposure to cigarette smoke d. Immune deficiency e. Crowded living conditions or lower socioeconomic status f. Daycare attendance 14. Age a. Infants and small children may have more difficulty breathing with respiratory tract infections b/c of the size of their airway b. 5 years i. Increase in mycoplasma pneumonia and β- strep infections e. Increased immunity with age → repeated exposure to organisms causes increased fjfjfjfjrjimmunity 15. Acute Infectious Disorders a. Common cold, sinusitis i. Signs and Symptoms: ↳Cough ↳Fever ↳Halistosis ↳Facial pain ↳Eyelid edema ↳Irritability ↳Poor appetite b. Influenza c. Pharyngitis i. Onset is quite abrupt ii. History is may include fever, sore throat, difficulty swallowing, headache and ghghghghghghghabdominal pain d. Croup syndromes

e. Respiratory syncytial virus (RSV) bronchiolitis f. Pneumonia i. inflammation of the lung parenchyma caused by a virus, bacteria, kmkmmmkmkkmMycoplasma,o r fungus 16. Location of Various Tonsillar Masses a. May be noted by: i. Asymmetric swelling of the tonsils ii. Shifting of the uvula to one side iii. Palatal edema 17. Nursing Care Post Tonsillectomy a. Promoting airway clearance i. Place child in side-lying or prone position ii. Continuous swallowing, especially while sleeping → early sign of bleeding fdffffffffb/c the child may be swallowing the blood that is trickling from the operative site b. Maintaining fluid volume i. Discourage coughing ii. Encourage fluids iii. Avoid citrus, brown, or red fluids c. Relieving pain i. Ice collar and analgesics with or w/o narcotics 18. Croup a. Occurs in the larynx b. Usually develops a barking-like cough at night c. may be accompanied by inspiratory stridor and suprasternal retractions 19. Bronchiolitis Respiratory Syncytial Virus (RSV) a. Signs and Symptoms i. Onset of illness with a clear runny nose (sometimes profuse ii. Pharyngitis iii. Low-grade fever iv. Development of cough 1 to 3 days into the illness, followed by a wheeze vvnnvnvnvnvnvnshortly after v. poor feeding b. Infants and children at high risk for serious RSV disease should be immunized ddjdjdjdjjdjdddwith palivizumab each RSV season c. Children older than 6 months of age should be immunized against influenza djddjdjdjdjdjdjdyearly. 20. Pneumonia a. Are classified according to: i. Site (lobar, bronchial, or intestinal, (or by) ii. etiologic agent (viral, bacterial, mycoplasmal, or are associated with dhdnfhfhfhfhfhfhaspiration of foreign material b. Lobar pneumonia c. Bronchopneumonia d. Interstitial pneumonia

e. Pneumonitis i. Localized acute inflammation of the lung w/o consideration or exudate ddjdjjdjdjdjdjdjdjassociated with pneumonia f. Treatment i. is primarily symptomatic, whereas bacterial pneumonia requires aggressive fjfjfjfjfjffjfjfjfjfjfmanagement with antibiotics and supplemental oxygen. 21. Tuberculosis a. Risk Factors i. HIV infection ii. Incarceration or institutionalization iii. Positive recent history of latent TB infection iv. Immigration or travel to endemic countries v. exposure at home to HIV-infected or homeless persons, illicit drug users, fjfjfjfjfjfjfjfjfjfjfjfpersons recently incarcerated, migrant farm workers, or nursing home residents vi. Children are at high risk for exposure and should be screened for infection 22. Chronic Respiratory Disorders a. Allergic Rhinitis i. Avoidance of allergens is critical in the treatment plan for the child with jjjjallergic rhinitis b. Cystic fibrosis c. Chronic lung disease (bronchopulmonary dysplasia, BPD) d. Apnea ↳Acute respiratory distress syndrome (ARDS) occurs following a primary insult such as sepsis, viral pneumonia, smoke inhalation, or near drowning. ↳Respiratory distress and hypoxemia occur acutely within 72 hours of the insult in infants and children with previously healthy lungs. 23. Asthma a.Pathophysiology i. Chronic inflammatory disorder of the airways ii. Bronchial hyperresponsiveness → heightened airway reactivity iv. In bronchial asthma, spasm of the smooth muscle of the bronchi and ddkdkdkdkdkdkbronchioles → increased resistance → causes constriction producing impaired respiratory function v. Limited airflow or obstruction that reverses spontaneously or with treatment b. S/S i. Nonproductive cough ii. Wheezing iii. Airway edema iv. Mucous production c. Risk Factors i. Age ii. Atopy iii. Heredity, Gender iv. Mother 80% of predicted) ii. Moderate (some limitation of activity, FEV 60% to 80% of predicted) iii. Severe (extremely limited, FEV 25), murmur (*machinery fkfkfkfk m  urmur*), at upper left sternal border or in L infraclavicular area. Murmur fkfkfkfk a udible throughout cardiac cycle ii. a harsh, continuous, machine-like murmur (usually loudest under the left fkfkfkfk c lavicle) is heard at the first and second intercostal spaces f. Diagnostic testing → ECHO g. Management of PDA i. Medical Preterm children = Indomethacin   to close PDAs ii. Surgical ligation if meds fail iii. Prophylactic antibiotics to prevent bacterial endocarditis h. Surgery i. b/w 1-2 years of age ii. prevents the return of oxygenated blood to the lungs. iii. The ductus arteriosus allows blood to flow from the higher-pressure aorta to fkfkfkfk t he lower-pressure pulmonary artery, causing a left-to-right shunt → no fkfkfkfk a dditional oxygenated blood (from the aorta) will return to the lungs through fkfkfkfk t he pulmonary artery

23. Coarctation of the Aorta (COA) a. Aorta is narrowed near the insertion of the ductus arteriosus b. There is increased pressure proximal to the defect c. causes high BP and bounding pulses in arms, weak or absent femoral pulses and fkfkfkfk lower extremities with low BP d. Signs of CHF in infants i. Condition can deteriorate rapidly ii. Older children may cause dizziness, fainting, and epistaxis from hypertension iii. Patient is at risk for ruptured aorta. Aortic aneurysm, or stroke iv. A thrill at the base, faint pulses, and systolic murmur heard best along the left fkfkfkfk s ternal border point to aortic stenosis e. Non surgical treatment i. Balloon angioplasty f. Surgical treatment i. Does not require bypass because defect is outside pericardium. Post-op f kfkfkfk c omplication is hypertension fkfkfkfk ii. Usually done before 2 years but there is a risk of recurrence

24. Aortic Stenosis a. Narrowing of the aortic valve b. Causes increases resistance in left ventricle, decreased cardiac output, left fkfkfkfk fkfkfkfk ventricular hypertrophy, and pulmonary vascular congestion c. L ventricular wall is hypertrophiedàincreased pulmonary vascular resistance and fkfkfkfk p ulmonary HTN d. L ventricular hypertrophyàdecreased coronary artery perfusion and increased risk of fkfkfkfk M  I e. Clinical manifestations: i. Infants w/ severe defects demonstrate signs of decreased CO. Faint pulses, fkfkfkfk f hypotension, poor feeding, tachycardia, murmur, exercise intolerance. fkfkfkfk  fkfkfkfk c hest pain, dizziness w/ standing ii. A narrowed pulse pressure is associated with aortic stenosis

f. Treatment i. Balloon angioplasty to dilate the valve; or surgery: Konno procedure [valve fkfkfkfk r eplacement]. May require repeat procedures.

25. Pulmonic Stenosis (PS) a. an obstruction to blood flowing from the right ventricleàPulmonary valve is fkfkfkfk s tenosed. Narrowing at entrance to pulmonary artery → R ventricular hypertrophy f fkfkfkfk a nd decreased pulmonary blood flow. b. Pulmonary Astresia i. Extreme form of PS ii. Is the total fusion of the commissures and no blood flow to the lungs c. R ventricle hypertrophy, R ventricular failure →R atrial pressure increases and may fkfkfkfk r eopen foramen ovale → Shunts unoxygenaetedblood to L atrium → systemic fkfkfkfk c yanosis → may lead to CHF d. Treatment i. Balloon angioplasty to dilate the valve. e. Surgical treatment i. Brock procedure (bypass to do valvotomy). Usually can repair w/ f kfkfkfk fkfkfkfk fkfkfcatheterization

26. Tetralogy of Fallot (TOF) a. Has four characteristics i. VSD ii. Pulmonic stenosis iii. Overriding aorta

iv. R Ventricular hypertrophy b. Depends on extent of pulmonic valve stenosis and size of VSD. i. IF VSD is large pressures are equal in  R and L ventricles. ↳Blood is shunted in the direction of the least resistance (pulmonary or fkfkfkfk fkf s ystemic vascular resistance). ii. If PVR is less than systemic vascular resistance, shunt will be right to left c. Clinical manifestations i. “Tet spells”or “blue spells”with acute episodes of cyanosis and hypoxia. ↳May be anoxic after feeding or w/ crying. d. Risks i. Emboli, LOC, sudden death, seizures e. Repairs i. Usually indicated when tet spells and hypercyanotic spells increase ii. Complete repair is usually done during 1st year of life 27. Transposition of Great Vessels a. Mixed blood flow i. Pulmonary artery leaves the L ventricle and the aorta exits from the R ventricle ii. There is no communication between the systemic and pulmonary circulations iii. Must have PDA or septal defect to permit blood flow b. Surgical treatment i. Arterial switch procedure ↳ resect and reanastomos great vessels ii. Coronary arteries may have to be reimplanted to supply myocardial circulation 28. Tricuspid Atresia a. Failure of tricuspid valve to develop b. No opening between R atrium and R ventricle → blood flows through ASD or fkfkfkfk p atent foramen ovale to L side of heart and through VSD to R ventricle and out to fkfkfkfk l ungs → oxygenated and deoxygenated blood mix in L side of heart → Systemic fkfkfkfk d esaturation and pulmonary obstruction. c. Treatment i. Shunt to increase blood flow to lungs. (Create atrial septotomy if ASD is fkfkfkfk s mall) ii. Bidirectional Glenn shunt (cavopulmonary anastomosis) at 6-9 months of age iii. Fontan(or modified Fontan) Pt must have normal ventricular function and a fkfkfkfk l ow pulmonary vascular resistance for the procedure to be successful. fkfkfkfk S  eparates mixed blood, but does not restore normal anatomy or fkfkfkfk fkfkfkfk h emodynamics. High surgical mortality rate (/= 95th percentile g. Treatment i. Restrict intake of cholesterol and fats

ii. Increase high density lipoproteins (HDL) iii. If no response to diet –→ Rx- Colestipol(Colestid), Cholestyramine fkfkfkfkkfkfkfkfkf(Questran) 35. Kawasaki Disease a. An extensive inflammation of small vessels and capillaries that may progress to fkfkfkfkfkfk involve the coronary arteries, causing aneurysm formation b. 3 Phases i. Acute ii. Subacute iii. convalescent phases c. Also called ‘acute systemic vasculitis” d. Primarily affects children >5 years old e. Causes inflammation and thrombi in coronary arteries Fk a dministration of gamma globulin and aspirin is  an important aspect of treatment f. Lasts 6-8 weeks, self limiting g. Without treatment of KD, 20%-25% have cardiac complications i. Dilation of coronary arteries (ectasia) ii. Coronary artery aneurysms (giant aneurysms > 8 mm) h. Symptoms i. high fever for 5 days that is unresponsive to antibiotics ii. chills, headache, malaise, extreme irritability, vomiting, diarrhea, abdominal fkfkfkfkfkkf a nd joint pain, distinctive rashes (strawberry tongue, palmar erythema), fkfkfkfkfkkf d esquamation of perineum, fingers and toes i. Treatment i. IV immunoglobulin initially and then long-term aspirin ii. Requires long-term monitoring of coronary arteries iii. One of the only times aspirin is part of the therapy for children j. Coronary complications i. High-dose intravenous gamma globulin and salicylate (aspirin) therapy is fkfkfkfkfkkf i ndicated to reduce the incidence of coronary artery abnormalities when given fkfkfkfkfkkf w  ithin the first 10 days of the illness 36. Digoxin a. used to improve cardiac function (improve contractility b. has a rapid onset and is useful for increasing cardiac output, decreasing venous fkfkfpressure, and, as a result, decreasing edema c. Cardiac output ↑, heart size and venous pressure ↓ d. Administration i. should be administered at regular intervals, every 12 hours, 1 hour before or 2 fkfkfkfkfkkf h ours after feeding ii. If the child vomits digoxin, the nurse should not give a second dose and fkfkfkfkfkkf s hould wait until the next scheduled dose iii. 60 beats/min is the cut-off for holding the digoxin dose in an adult. iv. 70 beats/min is the determining heart rate to hold a dose of digoxin for an fkfkfkfkkfkolder child.

v. 110 to 120 beats/min is an acceptable heart rate to administer digoxin to an fkfkfkfkkfk i nfant e. Toxicity S/S i. vomiting, neuro signs, visual disturbances 37. Hypercyanotic spells a. When b abies who have tetralogy of Fallot suddenly develop deep blue skin, nails fkfkfkfkkfk  a nd lips after crying or feeding, or when agitated b. caused by a rapid drop in the amount of oxygen in the blood. c. Relieving ‘tet spells’ i. Use a calm, comforting approach ii. Place the infant in a knee-to-chest position iii. Provide supplemental oxygen iv. Administer morphine sulfate (0.1 mg/kg IV, IM, or SQ) v. Supply IV fluids vi. Administer propranolol (0.1 mg/kg IV)

Key Pediatric Nursing Interventions 1. 8 rights of pediatric medications a. Right patient b. Right medication c. Right time d. Right route of administration e. right dose f. Right documentation g. Right to be educated h. Right to refuse 2. Pharmacodynamics versus pharmacokinetics a. Pharmacodynamics i. Is the behavior of medication at the cellular level ii. Affected by the physiologic immaturity of some body systems in a child jrjrjjffjfjfjfjfjfjfjfjfjfcompared to adults; response may vary based on genetic makeup b. Pharmacokinetics i. movement of drugs over time throughout the body via absorption, jrjrjjffjfjfjfjfjfjfjfjfjdistribution, metabolism, and excretion ii. affected by the child’s age, weight, body surface area, body composition, and jrjrjjffjfjfjfjfjfjfjfjfj d iseases affecting related organs (liver, kidney) 3. Medication Routes a. Oral administration i. When using an oral syringe to administer liquid medications, give the drug jrjrjjffjfjfjfjfjfjfjfjfjslowly in small amounts and allow the child to swallow before placing more jrjrjjffjfjfjfjfjfjfjfjfjmedication in the mouth ii. The toddler or young preschooler may enjoy helping by squirting the jrjrjjffjfjfjfjfjfjfjfjfj m  edication into his or her mouth. b. IM administration i. used infrequently because it is painful and children often lack adequate jrjrjjffjfjfjfjfjfjfjfjfjmuscle mass for medication absorption. ii. Injection sites ↳Infants: vastus lateralis muscle  (thigh) ↳Children after the age of 4-5: Deltoid muscle (arm) iii. Used to administer immunizations c. Sub Q administration i. Distributes medication into the fatty layers of the body ii. used primarily for insulin administration, heparin, and certain immunizations, jrjrjjffjfjfjfjfjfjfjfjf s uc...