Ped\'s Exam #3 Study Guide PDF

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Peds Exam 3 Chapter 27 

Polydactyly: additional 1 or + fingers or toes

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Syndactyly: 2 fingers or toes are fused

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Pectus Excavatum: funnel chest: indentation in the lower portion of the sternum

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Torticollis: sternocleidomastoid muscle is injured and bleeds during birth o Treatment is successful if the child loos in direction of affected muscle

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Talipes Disorder: club foot; require a series of casts or braces to gradually correct o If you try to straighten newborn’s feet to midline, if you can straighten then it is NOT a true talipes disorder and won’t require casting.

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Developmental Dysplasia of the Hip (DDH): improper formation of the hip socket o Assess:  Newborn:  Barlow sign: feeling of the femur head slipping out of the socket posterolaterally; start w/ knees apart, rotate midline and feel the femur head slip out of the acetabulum

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Ortolani sign: clicking or clunking sound when a displaced femoral head reenters the acetabulum; start w/ knees together, rotate laterally and hear femoral head slip into acetabulum Older children who can walk:  Trandelenburg Sign: stand on one leg (the affected leg), the test is positive if the pelvis drops on the side opposite of the leg they are standing on.

Treatment:  Pavlik harness: hold the hips flexed, abducted and externally rotated o Must be worn continuously 23*/day. Except for bathing  Monitor skin integrity

Ankyloglossia: tongue tied; assess for difficulty w/ feeding

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Pierre Robin Sequence Syndrome: triad of micrognathia; small mandible, cleft palate & glossoptosis (tongue is malpositioned downward) o Causes severe upper airway obstructionrespiratory distress  Keep side-lying or prone not supine for sleeping (until they can roll over) to avoid obstruction

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Esophageal Atresia: (EA) the lumen of the esophagus doesn’t form completely; results in a “blind pouch” that doesn’t connect to anything = no access to GI

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Tracheoesophageal Fistula: opening develops between the closed lower esophagus and trachea

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Assessment:

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Mom may have had polyhydramnios (too much amniotic fluid) do a VACTERL work up  Lots of mucus, “blowing bubbles & frothy sputum”, drooling, periodic cyanotic episodes, & drooling. Have suction available because they can’t handle their secretions Meconium plug syndrome: bowel obstruction from meconium; associated w/ Hirschsprung disease, cystic fibrosis, hypothyroidism o Tx: saline enema

Hydrocephalus: accumulation of an excess amount of CSF in brain o Assessment:  Measure head circumference at birth to make comparisons  Sunset eyes = sclera shows above the iris because of upper lid retraction  Assess fontanelles for width and tension o Tx:  If caused by over production of fluid, then diuretic is given  If more extensive, a VP (ventriculoperitoneal) Shunt (drain excess fluid from ventricles into peritoneum Neural Tube Disorders: not all neural tube disorders involve the spinal cord

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Spina bifida: collective term for all spinal cord disorders Spina bifida occulta: benign disorder; posterior side of vertebrae fail to fuse; dimpling of skin or tuft of hair is a sign Meningocele: the meninges (pia, arachnoid & dura maters) herniate through unformed vertebrae = protruding circular mass

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Tx: immediate surgery to replace the meninges and close the gap in the skin to prevent infections Meningomyelocele: common birth defect affecting the CNS; the meninges and the spinal cord protrude through the vertebrae; spinal cord ends at protrusion; causes partial or complete paralysis  Associated w/ hydrocephalous  Protect the sac  Requires surgery to close the gap

Chapter 40: Ped’s Respiratory Disorders     

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Cough: reflex; nerves in respiratory tract stimulated by dust, chemical, mucus or inflammation Paroxysmal Coughing: series of expiratory coughs after a deep inspiration; common w/ pertussis (whooping cough) or aspiration Tachypnea: increased RR; 1st indication of airway obstruction in children o depth and quality of respiration are also important Anoxia: cells in the body lack O2 Hypoxia: decreased oxygen in body cells  children/infants become anxious and restless o Cyanosis: blue tinge to the skin; indication of hypoxia  Degree of cyanosis is not an accurate indicator of the degree of hypoxia Hypoxemia: lack of O2 in the blood o s/s: tachypnea, decreased alertness & activity, inability to feed because can’t suck and breathe at the same time retractions: more forceful inspiration than normal; required to inflate lungs d/t airway obstruction, stiff noncompliant lungs, intrapleural pressure is decreased to the point that the intercostal spaces draw inward

Adventitious Sounds: o Vibrations: air being forced past and obstruction like mucus o Rhonchi: snoring o Stridor: harsher, strident sound on INSPIRATION; base of tongue or in larynx o Wheezing: EXPIRATORY whistle; heard when obstruction is in the lower trachea or bronchioles o Crackles/rales: snapping sound of alveoli popping open; heard when alveoli become fluid filled

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o Will have diminished breath sound when alveoli are so filled that air can’t enter them Hyperinflation: inability to exhale completely; air is chronically trapped in alveoli; aka pigeon breast Spirometry: most common test of lung function in children o Measures the peak expiratory flow amount of air that can be forced out of the lungs Pharyngitis: infection and inflammation of the throat o Caused by an ADENOVIRUS Streptococcal pharyngitis: can lead to acute rheumatic fever & glomerulonephritis if not treated Epistaxis: nosebleed; very common in children o Keep children in upright position with head tilted slightly forward, not back into the nasopharynx o Hold pressure to the cartilage on the sides of the nose with your fingers for 10 minutes Congenital laryngomalacia/tracheomalacia: weak laryngeal structure that collapses more than usual on inspiration o Stridor: high pitch crowing sound on INSPIRATION  Caused by a blocked airway Croup: laryngotracheobronchitis; inflammation of the larynx, trachea, & major bronchi. o caused by para-influenza virus o assessment:  barky cough (like a seal), dyspnea, inspiratory stridor, retractions o tx:  cool moist air & corticosteroid (dexamethasone) or Racemic Epinephrine via nebulizer to reduce inflammation bronchiolitis: inflammation of fine bronchioles & small bronchi o common in children < 2 years of age o main cause is RSV- Respiratory Synapsical Virus  RSV: droplet lives 6* on surfaces  Hand hygiene prevents the spread  Droplet precautions  Keep RSV pts together to prevent spread asthma: chronic inflammatory disorder of the airways  obstruction of the bronchioles o assessment:  get thorough hx  wheezing {audible on expiration}; dyspnea, cough  pulmonary function tests (studies): most accurate tests for diagnosing asthma and its severity o tx/management:  bronchodilators: inhalers; beta2 agonists (albuterol, terbutaline)  cholinergic antagonists: blocks parasympathetic nervous systemrelief of acute bronchospasms  anti-inflammatory agents: decrease airway inflammation (prednisone, solumedrol)  combined meds: steroid w/ long acting beta2 agonist atelectasis: alveoli collapse

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o management: keep child in semi-fowlers position for the best lung expansion tuberculosis: (TB) must have sputum culture to positively confirm a diagnosis of active TB Cystic fibrosis: respiratory disorder; mucus glands secrete and excess of mucus, and it is thicker than normal; causes obstruction of lungs, pancreas, liver, small intestine & reproductive system o Pancreas involvement: digestive enzymes necessary for the digestion of fat become so thick they plug the ducts; eventually mucus cells atrophy and stop producing enzymes. Stools become large, bulky, & greasy (steatorrhea) o Assessment:  Sweat testing: collect sweat from 2 different sites  Confirmation of CF o Therapeutic Management:  Medications  Digestion: o Pancrelipase: enzyme replacement to help w/ digestion of fats  Administer capsules w/ all meals & snacks; can open capsules and sprinkle on food  Respiratory: o Proventil/albuterol: short acting beta2 agonist o Atrovent: cholinergic antagonist (anticholinergic) o Dornase alfa: (pulmozyme) decreases the viscosity of mucus & improves lung function  Assess sputum thickness & pt ability to expectorate  Antibiotics: specific for pulmonary infection o Tobramycin o Ticarcillin o Gentamicin  Vitamins o Daily multivitamin o Fat soluble vitamins Therapeutic techniques for Respiratory Disorders: o Chest physiotherapy: CPT;  Change position  Percussion: striking a supped or curved palm against the chest to determine the consistency of tissue beneath surface area  Vibration: as child exhales vibrate hand against child’s chest; mechanically loosens secretions o Nebulizers: mechanical devices that provide a stream of moistened air directly into the respiratory tract o Pharmacologic Therapy:  Nasal sprays: moisten & loosen nasal secretions  Antihistamines: reduce mucus production in presence of allergies  Corticosteroids: reduce airway inflammation; brief use of nasal decongestants may be advised  Bronchodilators: open lower airway

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 Antibiotics: may be ordered if the illness is caused by a bacterial infection Improving oxygenation: o Tracheotomy: procedure to create an airway  Tracheostomy: opening in the trachea to create an artificial airway  Primary nursing responsibility when a child with trach tube eats- prevent aspiration of food or fluids into the tube o Incentive spirometer: peds use 4 times daily; to do it right, use on INSPIRATION

Chapter 41: Cardiac Disorders   

Congenital heart disease: anatomic defects born with o Risk factors: maternal: infection, ETOH/drugs, DM Acquired Heart Disease: disorders that develop after birth o risk factors: rheumatic fever, hypertension & hyperlipidemia Fetal Circulation: 

Placenta oxygenates & removes carbon dioxide from the blood  3 Fetal Shunts o Patent Foramen Ovale: flapped opening between atria. Oxygenated blood bypasses the lungs and continues to left ventricle and aorta o Patent Ductus Arteriosus: connects pulmonary artery to the aorta; oxygenated blood bypasses lungs o Ductus Venosus: shunt that allows oxygenated blood in umbilical vein to bypass liver. Blood then enters IVC & enters right atrium

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General Assessment of Heart Disorders o Appearance: o Check for cyanosis in mucous membranes of the mouth  If cyanosis increases w/ crying, cardiac dysfunction is suggested. Indicates infant can’t meet the increased circulatory demands of exertion o Ruddy complexion: body has overproduced RBCs (polycythemia)

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Murmurs: whooshing sound o Innocent heart murmur: sound heard is not concerning o Organic heart murmur: sound heard is a result of heart disease or congenital disorder

Diagnostic tests: o Transthoracic Echocardiography: noninvasive US of the heart gives detailed information of heart structure and function  Primary diagnostic test for congenital heart disease o Cardiac catheterization: invasive test; catheter pass through large vein/artery into the heart.  Diagnose or repair defects  Evaluate dysrhythmias  Access for catheterization is frequently obtained in the femoral vein OR artery but radial or neck access can be used o Post procedure: assess insertion site for bleeding or hematoma  Prevent bleeding by maintaining the affected extremity in a straight position for 4-8 hours Congestive Heart Failure: inability of the heart to supply the oxygenated blood demanded by the body o Clinical Manifestations: o Cool extremities o Peripheral edema o Nasal flaring  Position in Semi-fowlers ↑Pulmonary Blood Flow Disorders o Patent Ductus Arteriosus: (PDA) ductus arteriosus (between pulmonary artery & aorta) doesn’t close ↑ pulmonary blood flow o Assessment:  Wide Pulse Pressure (90/40)  Bounding pulses o

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Atrial Septal Defect: hole in septum between R & L atria↑ pulmonary blood flow o Assessment:  Loud, harsh murmur w/ fixed split 2nd heart sound

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Ventricular Septal Defect: MOST COMMON DEFECT IN CHILDREN

↓Pulmonary Blood Flow Disorders o Tetralogy of Fallot:  4 Components:  Pulmonary artery stenosis o Degree of cyanosis is directly proportional to the degree of pulmonary stenosis  VSD  Overriding Aorta  Right Ventricular hypertrophy

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Assessment:  Hypercyanotic spell or “tet spell”: Episodes of acute cyanosis & hypoxia Management:

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Teach Parents: When child becomes cyanotic & dyspneic, place child in a knee-chest position to increase systemic vascular resistance & reduce R to L shunting

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Obstruction of Blood Flow o Coarctation of the Aorta: narrowing of the lumen of the aorta  Assessment:  ↑ BP & pulses in Upper Extremities  ↓BP & weak or absent femoral pulse o Absence of palpable femoral pulses from the decrease BP to lower body may be the only symptom

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Acquired Heart Disease: o Kawasaki Disease: febrile, multisystem disorder that occurs in children before puberty.  Vasculitis: inflammation of blood vessels; main and life-threatening symptom because it can lead to formation of aneurysms & MI  Strawberry tongue w/ white coating  Enlarged lymph nodes  Observe for symptoms of bowel obstruction; enlarged lymph nodes in abdomen can compress intestines

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Tx:

 Gamma globulin (IVIG)  ****Aspirin: high dose 80-100 mg/kg/day divided q 6* Rheumatic Fever: inflammatory diseased caused by untreated strep throat infection  Subcutaneous nodules over bony prominence, large joints  Erythema marginatum: rash that appears and disappears rapidly  Tx: antibiotics ranging from 5 years to indefinitely  Encourage periods of rest to ↓ cardiac workload  Can use ASA for tx

Cardiomyopathy: most common cause of heart transplant in children > 1 y.o.  Dilated: most common  Hypertrophic: hypertrophy of Left Ventricle  Most common cause of sudden cardiac death in an otherwise healthy child  Arrhythmogenic Right Ventricular: rare & inherited dz. Causes ventricular tachyarrhythmias & sudden death in young people & athletes o Hypertension: adolescents w/ HTN are advised to not use oral contraceptives (they elevate BP)  Criteria to define childhood HTN: systolic reading above the 95th percentile for the child’s age Cardiac Surgery: chief cure for congenital heart disease o Hypothermia: used to ↓ body temp to reduce metabolic need & slow the HR o Postoperative Care:  Prevent pooling of lung secretions: suction PRN; especially if using ventilator o

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Chapter 42: Ped’s w/ Immune Disorders

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Immune Response: body’s action plan devised to combat invading organisms o Antigen: foreign substance o Immunity: body’s ability to destroy antigens o Allergen: specific type of antigen that causes and IgE (allergic) antibody response o Humoral Immunity: use B lymphocytes (memory cells) cells that secrete large quantities of immunoglobulins (antibodies {think air force}); fight specific antigens the body has been exposed to before  IgM: Massive response- 1st on scene w/ antibodies specific to antigen  IgG: body recoGnizes a previously seen antigen; IgG’s are immediately produced  Infants have maternal IgG protection for 6 months  Complement activation: cascade response by different proteins that when activated by an antigen cause increased vascular permeability, smooth muscle contraction, chemotaxis (chemical signal calling leukocytes to the area), phagocytosis, & lysis (killing) of foreign antigen  Deficiency in humoral immunity = ↓ antibodies o Cell-Mediated Immunity: hand to hand combat by T lymphocytes; 70-80% of lymphocytes; causes transplant rejection  Developed in bone marrow, but matured (trained) in thymus gland  Cytotoxic  Helper T-cells  Suppressor T-cells HIV/AIDS: virus causes disfunction in immune system by attacking specific T-cells (CD4); symptoms of AIDS in children most commonly begin as frequent respiratory infections o 3 classifications of HIV in children o Tx: Zidovudine: during pregnancy goal is to keep CD4 cell count at >500 cells/mm3  Action: stops replication of the virus; ↓ risk of maternal-fetal transmission  Nursing Considerations:  Administer IV over 60 minutes  Administer around the clock for maximum effectiveness  Monitor labs  Encourage small frequent meals to help w/ loss of appetite & taste  Rx can cause paresthesia’s; teach pt and parents about safety  Only reduces risk of transmission placentally; must remain vigilant w/ hygiene & infection control measures Hypersensitivity: o Type I- Anaphylaxis: IgE; caused by exposure to insect bites, Rx, latex, and foods;  Food allergy: most common cause of anaphylaxis o Type II- Cytotoxic Response: Blood transfusion reaction; only foreign cells are destroyed o Type III- Immune Complex: Autoimmune o Type IV- Cell-Mediated Hypersensitivity or Delayed Hypersensitivity: lymphocytes react to antigens; macrophages called to area; inflammatory response occurs that destroys foreign tissue; ex: PPD TB test; transplant reaction, contact dermatitis Reactions to Allergens o Urticaria: swelling & itching; often from ingested antigens

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Contact dermatitis: rash: related to antigen that touches the skin  Example of a delayed (Type IV) hypersensitivity response

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Wheal: small raised bump; looks like mosquito bite Flare: redness that surrounds a wheal  Wheal & flare will appear at site of allergy test from the release of histamine by mast cells

Tolerance: sustained unresponsiveness; when contact w/ allergen can’t be avoided immunotherapy (hyposensitization) is used to produce tolerance Anaphylaxis: TRUE EMERGENCY so fast interventions are necessary o Immediate therapy: IM EPI injection or oral antihistamine o Long-term therapy: corticosteroids; cyclosporine (immunosuppressant) & monoclonal antibody usually used in older adolescents/adults Allergic Rhinitis: risk factor for developing asthma  Perennial Allergic Rhinitis: allergen present year-round; house dust mites, pet hair o assessment:  pale nasal mucous membrane & blackened area under eyes (allergic shiners)

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Avoid ALLERGENS!!!! Rx:  Antihistamines: educate about rebound effect (after 3 days of use when stop using, will have increased congestion) o Topical steroid used to reduce itching; use sparingly in young infants-thing layer  Immunotherapy  develop tolerance Lichenification: thick, leathery skin; occurs from constant rubbing/itching

Elimination Diet: used w/ food allergies; if uncertain what allergy is, or suspect allergy, start removing most common allergens from diet (peanut (85% of fatalities from food anaphylaxis), milk, wheat, egg, soy, seafood, tree nuts) o Keep a food diary  Colic/fussy eaters could be sign of food allergy

Chapter 43: Infectious Disease in Children 

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Stages of infectious disease o Incubation: time between invasion and onset of symptoms; microorganisms grow & multiply in host o Prodromal: time between the beginning of nonspecific symptoms and the onset of disease specific symptoms o Illness: specific symptoms occur o Convalescent: time betwe...