Peds test 2 - summary for pediatric exam 2 PDF

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UNIT 5: CHILD MALTXT CHILD MALTXT – Any form of injury /substandard care done to a child by a caretaker  Emotional/physical abuse/neglect, abandonment, sexual abuse, abandonment  Involves acts of omission(neglect) & commission (abuse)  Injury inflicted by caretaker  Child Abuse Prevention & Txt Act - mandatory reporting, (800) 96 - abuse  Protects kids, prevents abuse, provides counseling for abusers EMOTIONAL ABUSE=delib attempt to destroy or significantly impair a child’s self-esteem or competence. Reject isolate, terrorizing, ignoring, corrupting, verbally assaulting or over-pressuring the child.  Hard to determine, but if there is an unexplained change in the child’s behavior is 1 clue. PHYSICAL ABUSE=delib infliction phys injury on child==act or fail to act that result in imminent risk serious harm, death, physical or emotional harm of child by parent or caretaker who is responsible for the child’s welfare. Characteristics of Maltxted Child  Resemblance of someone abuser dislikes  Child w/ chronic condition or disability  Feeding difficulty, or difficulty bonding (preemies & facial malformations).  < age 3, female Characteristics of Abusing Parent  Few supportive friends or relatives Difficulty coping w/stress & controlling anger  ↓ self-esteem, lack of trust for others  Unrealistic expectations of child  Younger parents, single parent family  Abused as child Environmental Characteristics -Abuse more common in times of crisis: loss of job, marital problems, chronic stress including poverty, poor housing, frequent relocation, alcoholism & drug addiction. Page

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MANIFESTATIONS OF PHYSICAL ABUSE  Unexplained burns - soles, palms, buttocks (submergent burns)  Injury incompatible w/ history (was on floor, child fell & got skull fracture)  Extreme w/drawal or aggression  Cry when abuser comes, No eye contact, inappropriate pain response  Welts, belt marks or fractures at various stages of healing Munchausen Syndrome by Proxy  Caretaker fabricate child’s illness → unnecessary txts/procedures, well-inform, cooperative, attent to child  Caretaker perceives child as unhealthy

 S&S Of Munchausen Syndrome  Unexplained, prolonged, recurrent or extremely rare illness Illness unresponsive to txt  Discrepancies tween clinical findings & history, S/S occurring only in parents presence  Parent knowledgeable bout illness, procedures, & txt, interested in interacting w/health team members  Parent very attentive toward child (refuses to leave hospital)  Family members w/similar symptoms Management Of Munchausen Syndrome  Long term psychological therapy for parent, removal of child from home  May even get surgery May not be able to go back home  ASSESS: freq hospital, prolong illness, extensive hx by caretaker, fam hx of disorder or sibling death. Shaken Baby Syndrome  Baby has large head to body ration, weak neck muscles & large amt of H2O in the brain; violent shaking causes the brain to rotate w/in the skull resulting in shearing forces tearing blood vessels & neurons.  Vigorous manual shaking of child < age 3 [book says under 1]  Held by extremities or trunk & shaken vigorously  Subdural (intracranial) hematoma » intraocular bleeding  Manifestations: FTT, SZ, apnea, vomiting, retinal bleeding, intracranial bleeding respiratory, seizures, alternating levels of consciousness, profound mental cognitive & motor impairments. Abnormalities, microcephaly, blindness, visual disturbances, can become blind have microcephaly. Management Of Shaken Baby Syndrome100% preventable  Teach parents that babies cry for a reason.  Teach parents to check all needs of baby & then put in crib (safe crib) & walk away.

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SEXUAL ABUSE –  Use of child for sexual purposes  Prostitut (child in sex act for profit), rape, incest (=any family memb, not necessarily blood relation), molestation (indecent liberties), pornography (photographing children in sex acts alone or w/adults  Peak age 6 – 9, average age 4  Abuser well-known to child; someone they trust==Involves secrecy reinforced by threats  Most of the time they don’t tell parents; if they do, mom often doesn’t believe them  Forensic be done w/in 72-96 hrs. Evidence diminish w/in 24 hrs, may get evidence from cloth or linen  Genital tissue heals quickly & often w/o scars. Verbal/Emotional Abuse=Shame, insult, embarrassing remark to child, reject, isolate, terrorize, ignore, corrupting, take toys

Child Neglect=any form substandard care (can’t provide basic needs)  Types Of Child Neglect  Physical Neglect: inadequate clothing/nutrition/housing/supervision/education/medical care

 Emotional Neglect: lack attn/affectn, fail to correct unacceptable behavior, fail to look or touch child  Medical neglect: noncompliance w/ medical regimen, missed appointments  Educational neglect=absence of age appropriate knowledge  Characteristics of Neglected Child  Listlessness, w/drawn  Lack of eye contact, inappropriate clothing  Developmentally delayed (FTT)  Emotional/verbal abuse, embarrassing remarks to child  Parental characteristics=lack of knowledge Child Abandonment =Leaving child unattended for extended Pd of time  Nursing Management  Assessment & reporting suspicions Provide support  Play therapy – aggressive kids or kids who don’t want to go home  Time out = best form of punishment  Consistent caregivers

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FAILURE TO THRIVE  FTT = Medical Diagnosis; FLK – Funny Looking Kid = Medical Diagnosis  Inadequate growth due to inability to obtain/utilized required calories.  Incidence  Approx. 2% hospital admissions  Height & weight < 3rd(5th) % on growth chart  Etiology Of FTT  Organic: Physical/structural impairment → growth failure, cardiac problem (s↓ feeders, hard to breathe), HIV, GI problem, Reflux, malabsorbtion, endocrine dysfunctn, cystic fibrosis  Non-organic: psych=impair caregiver-child relation. Psychosocial= inadequate nutrit info by parent, defcy in maternal care or disturbance in maternal child attach or disturb in child’s ability to separate from the parent, leading to food refusal to maintain attention.  Idiopathic: unexplained factors by usual organic & environ etiologies but also be classified as NFTT.  Other: poverty, health beliefs(vegetarian), inadequate nutritional knowledge, family stress, feeding resistance, insufficient breast milk, hyperthyroidism, trisomy 21 & 18  Manifestations  Weakness  Delayed development  W/drawn, apathy, poor hygiene  Absence of eye contact, minimal smiling  Feeding/eating disorders: PICA (eating something non organic), spitting up  Medical Management  Unlimited feed w/ DFA (diet for age)

 Catch-up growth – a rate of growth greater than the expected rate for age  Behavior modification & feeding rituals  Nursing Management  4 goal=correct deficy & achieve ideal wt for ht, allow catch-up grwth, restore optimum composition, educate parents regarding child’s nutritional requirements & appropriate feeding methods.  Assessment (Bernard Total Nursing Assess Tool) – up to 12 mths old  Daily weight - same time, clothes, scale (use appropriate scale for age)  Avoid interruptions during meals  Strict I & O  Positive reinforcement  Feed fortified rice cereal & vegetable oil. Supplement w/ zinc & iron, consume minimal fruit juice.  Prevention – teaching parents—parent’s anonymous & parents united international.  Priority is to remove child from abusive situation to prevent further injury.  Teach parents successful feeding strategies  3 INTERLOCKING CIRCLES 1) Child – health status, temperament (easy/difficult) 2) Caregiver – health status, socioeconomic, knowledge 3) Environment – safety, supportive UNIT 6: CARDIOVASCULAR DISORDERS REVIEW OF FETAL & NEONATAL CIRCULATION Foramen ovale & PDA open when child 1st born Vena cava→ right atrium thru the foramen oval to the left atrium (better oxygenated blood enters left atrium/ventricle to be pumped thru aorta to the head & upper extremities) →right atrium from superior vena cave→ tricuspid valve into right ventricle→ pulmonary artery which is shunted →ductus arteriosis. Blood by the umbilical vein. About half of this enters the fetal ductus venosus →inferior vena cava. → right atrium. →opening between the right and left atrium (the foramen ovale), →left atrium from the right atrium, thus bypassing pulmonary circulation.→ left ventricle, →aorta into the body. Some of the blood entering the right atrium does not pass directly to the left atrium through the foramen ovale→right ventricle →pulmonary artery. In the fetus, there is a special connection between the pulmonary artery and the aorta, called the ductus arteriosus, which directs most of this blood away from the lungs W/ 1st breath, lungs expand, causing pulmonary vasodilation. Pulmonary pressure fall & systemic pressure rises causing foramen ovale to close as pressure in left atrium exceeds pressure in right atrium. Ductus arteriosus closes in presence of ↑ O2 concentration in blood. Septal defect occurs, blood flows from hi pressure (L side) to ↓ pressure (R side) = left-to-right shunt. Anomalies resulting in cyanosis may result from change` in pressure so that blood shunted

from R to L side of ht (right-to-left shunt). Cyanosis then results from oxygenated & deoxygenated blood mixed in the heart chambers. CHF  Right sided failure= R ventricle unable to pump blood to pulmonary artery= ↑ pressure in R atrium & systemic venous circulation. Systemic venous htn can cause edema.  Left sided failure= unable pump blood to systemic circulation = ↑ pressure in L atrium & pulmonary veins=lungs become congested w/ blood. Ht can’t maintain adequate CO, ↓ flow→kidneys continue to stim Na+ & H2O absorp=fluid overlod & lung congest

 S&S of CHF  Impaired Myocardial Fxn= tachycardia, inappropriate sweat, ↓ urinary out, fatigue, weak, restless, anorexia, pale, cool extremities, weak periph pulses, ↓ BP, gallop rhythm, cardiomegaly  Pulmonary congestion=tachpnea, dyspnea, retractions, flaring nares, exercise intolerance, orthopnea, cough, cyanosis, wheezing, grunting  Systemic venous congest= wt gain, hepatomegaly, periph edema, Ascites, neck vein distention. CONGENITAL HEART DEFECTS=Major cause death in infancy Incidence=8 per 1000 live births or 1% of all births  Etiology Unknown  Multiple factor: maternal rubella syndrome, poor nutrition, Gestation DM, insulin dependent diabetes, genetic, FAS, Down syndrome, TORCH infections, PKU

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TYPES OF CONGENITAL HEART DEFECTS  Cyanotic= ↓ blood flo lead to tetralogy of fallot & tricuspid tresia. Also mixed blood flo=lead to transposition grt arteries, total anomalous pulm venous return, truncus arterisosus & hypoplastic L ht synd  Acyanotic=↑pulm blood flo=lead to atrial septal defect, vent septal defect, patent ductus arteriosus & AV canal also obstruct to blood flo from vents=coarctation of aorta, aortic stenosis & pulmonic stenosis.  In both: (some cyanosis still exists)/Obstructive(narrowing or stenosis of valve) Page

 ↑ pulmonary blood flo=from L side heart to R side.=↑ volume on R which ↑ pulmonary float expense of systemic flo. Show signs of CHF, ASD, VSD & patent ductus arteriosus  ↓ pulmonary blood flo= obstruction & an anatomic defect tween R & L side heart. Pressure on R side ↑ (difficult exiting)=exceeds L side pressure=desaturated blood shunts Right to Left=hypoxemia & cyanotic  Obstruction to blood flo= stenosis caused. Pressure ↑ before obstruction & beyond ↓. Coarctation of aorta, aortic/pulmonic stenosis, CHF  Mixed blood flo=pulmonary congestion occurs VENTRICULAR SPETAL DEFECT (VSD) – abnormal opening tween R & L ventricles

Incidence-- MOST COMMON TYPE OF CHD--1/3 of all CHD’s (20%) If the opening is small, there is a L→R shunt, the septum is not complete If there is a large hole=Isomeizer synct…there is a R→L flo  Pathophysiology - Aycyanotic  Abnormal opening tween R & L ventricles » blood shunted from high pressure L ventricle to R (L to R shunt) » oxygenated blood entering pulmonary circulation » ↑ pulmonary (lung) circulation [hemodynamic] » ↓ cardiac output & R ventricle hypertrophy (larger for accommodation).  Manifestations (may be asymptomatic (depends on how big the hole is)  FTT -less nutrients  CHF (more blood to the lungs= =pulmonary edema)  ↓ CO(↓ blood flow=↓CO=↓nutrients/O2→body (=wt loss, growth retard)  Dyspnea – air hunger resulting in labored or difficult breathing  Crackles, ↓O2 sats, >cap refill  R ventricular hypertrophy – ↑ in size (more blood in R vent=hypertrophy b/c of accommodation of the extra amount of blood, muscle grows  Pansystolic murmur=ht murmur heard thru systole heard best L sternal border.(risk for bacterial endocarditis) S1

 Medical Management (laproscopic or open surgery)  Pulm banding (band around main pulmonary artery to ↓ pulmonary blood flo= preferred approach  Card. Cath: Rashkind device–[balloon atrial septostomy] close of ASD, VSD PDA w/double disk prosthesis=placed during cardiac catheterization. It is used as an alternative to septostomy.  Surgical: Purse string – a suture entering & exiting around the periphery of a circular opening. Drawing the suture taut closed the opening or Dacron patch (can be open or laproscopic) via CABG [Coronary artery bypass graft] PostOp complications=residual VSD & conduction disturb

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ATRIAL SEPTAL DEFECT (ASD) – opening tween R & L atrium  Incidence 12% of CHD More common in females (2x)  Pathophysiology – acyanotic = L-R shunt  Blood shunt from ↑ press L to ↓ press R atrium → oxygenated blood in R atrium → pulmonary blood flo [hemodynamic] → pulmonary symptoms w/out txt (foramen ovale did not close)  Volume is well tolerated by right ventricle b/c it is delivered under much ↓ pressure than w/VSD. There is R atria & ventricular enlargement, cardiac failure is unusual.  ASD 1= open at ↓ end of septum (may have mitral valve abnormal), ASD 2=open at center septum. Sinus venous defect=open at jxn of superior vena cava & R atrium.  Manifestations (asymptomatic or)  Growth retardation (FTT)  ↓ CO – amount blood pumped from left ventricle to aorta  Dyspnea

 CHF  Soft systolic murmur – erbs point (not as loud (atria is smaller than vent)  Medical Management  Card. Cath. – Septal Occluder [not open heart]  Surgery: before school age, Dacron patch PATENT DUCTUS ARTERIOSUS (PDA) - absence in closure of fetal ductus arteriosus  Incidence=12% of CHD’s, ↑ in LBW  Pathophysiology – acyanotic = L-R shunt  Opening of patent ductus » blood shunted from aorta to pulmonary artery » blood recirculated through lungs [hemodynamic] » pulmonary vascular congestion  Manifestations (may be asymptomatic)  Widened pulse pressure – subtract diastolic from systolic for pulse pressure  Resp. distress  Bounding pulse  Machine-like murmur – Gibson murmur (Erb’s point)  FTT  L Vent hypertrophy  Medical Management  Pharmacological: prostaglandin inhibitor (smooth muscle constrictor) o Indomethacin (indocin) = closes hole  Closure during Card. Cath.  Surgical: division & ligation

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TETRALOGY OF FALLOT ***Ms. Jessamy’s favorite  Typical presentation: 1. Ventral Septal Defect (VSD) if large, deoxy blood →aorta, this is a R→L shift 2. Pulmonary Stenosis (smaller) blood in R vent=hypertrophy for accomodation 3. Overriding Aorta (aorta moves out of place 4. R Ventricular hypertrophy (R-vent enlarges)  Incidence 9% of CHD’S Associated w/ FAS, thalidomide  Pathophysiology - cyanotic Small VSD hole= L to R shunt; Large VSD hole = R to L shunt  VSD→equal press in R & L vents. Pulm stenosis→↓ pulm blood flo [hemodynamic] & cyanosis →hypercyanotic episodes →↑ systemic vasc resist ↑ R to L shunt blood compromising circ to lung  Vent press→ R→L shunt, pulmonary stenosis →↓blood to lungs & cyanosis→hypercyanotic episodes→↓systemic vasc resist→ squatting episodes→↓pulm vasc resist & ↑ periph vasc resist→ more blood to lungs   Manifestatons=surgery!

 Hypercyanotic (denoting extreme cyanosis) episodes (tet spells) ↓ systemic vascular resistance – precipitated by crying, feeding, defecating  Polycythemia – an excess of RBC’s production to ↑ O2  Clubbing (check by seeing nails – no space tween nails = clubbing should be 160° becomes 180°), growth retardation  Squatting episodes – knee-chest – causes systemic vascular resistance = more blood to lungs  Circumoral Pallor, tet spells  Medical Management  Hypercyanotic episodes – knee-chest position, O2 therapy-100%, morphine (dilates respiratory system for more O2 to enter) can also use dopamine or neosenephrine hydration, Inderal (propanolol) – for heart rate, blood transfusion with packed cells  Palliative: Blalock-taussig shunt =anastomosis of subclavian artery to pulmonary artery on same side. Helps improve oxygenation.  Surgical: complete repair before age 1 – indication: frequent tet spells

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COARCTATION OF AORTA - narrowing of aortic arch  Pathophysiology – acyanotic = no shunt  Narrow of ascend aortic arch→↑ resist flow to systemic circ→↑press in proximal & ↓ press in distal extremities  Manifestations  B/P in upper extremities >↑(high in head & upper extremities)  Bounding pulses in arms, weak or absent femoral pulses & cool ↓ extremities w/ ↓ BP  CHF – this happens in all disorders  Dizzy, fainting, headaches, epistaxis from htn  Management  Nonsurgical: balloon angioplasty, mechanical ventilation & inotropic support.  Surgical: ligation & end to end anastamosis (for < 6 mos=surgery of choice) post op htn txt w/ IV Na+ nitroprusside, esmolol, ace inhibitors or beta blockers. NURSING MANAGEMENT OF CV DISORDES  Monitor VS, I & O (Retain fluids & poor feeders), edema  Assess for adventitious breath sounds (crackles), therapeutic & side effects of meds.  ↓ cardiac demand, ↓respir distress, maintain nutrit status, assist measures to promo fluid loss (diuretics)  Help family adjust to disorder Cultural Factors? Rheumatic fever 3rd world . Htn ↑ Afr Am peds. Kawasaki (acute systemic vasculitis) synd every grp

Diagnostics  X-RAY: heart & assoc. organs  24 hr. Halter Monitor: 24 hr. record – at rest & activity  ECG: electrical activity white = right; green = spleen; black = L atrium  ECHO: size of heart chambers, location & motion of valves; 2d, MMode, Fetal, transpharengeal, Doppler=blood flo

 Cardiac catherization= (meas hemodynamics=press & O2 ht chamber), angiography (contrast material to ilum ht structure & blood flo pattrn), biop (sample ht), EPS (catheter w/electrode read electrical activity)  MRI: thickness, shunts, tumors, structure & function of valves.  Cardiac stress test (monitor ht rate, BP, ECG & O2 consumption at rest & during progressive exercise  Warn pt closed space, remove metal/jewelry CARDIAC CATHERIZATION: - radiopaque cath. through vessel to heart. Aft tip of catheter is w/in heart chamber, contrast material is injected & films taken. Diagnostic=study to dx symptomatic infants before surgical repair. Threaded right or left side- venous approach is righ side thru femoral vein, left side is arterial approach—not used as frequently. Interventional=balloon catheter inserted to dilate a stenotic valve Complications: hemorrhage from entry site, ↓ grade fever, vomit, loss of pulse in catherized extremity from a clot, hematoma, transient dysrhythmias, stroke seizure, tamponade & death.  Pre-Catheterization Considerations  NPO 6 – 8 hrs. – make sure they are getting IV fluids  Baseline VS, Wt & ht allergies iodine  Permit signed (invasive)  Check for allergies to the die or shellfish  Check for diaper rash, can cancel test.  Mark on child locations of dorsalis pedis & posterior tibial pulses before going to catherization room.  Pulse ox important for this procedure  Dye can cause warm feeling, salty taste  Lights usually off, locate pulse sites  Usually a R venous approach; most common thru the R groin

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 Post-Catheterization Considerations  VS [Q15x4; Q30x2; Q1x4; Q4 hours]  Cardiac monitor & pulse ox  Position in bed (flat in bed 6-8 hrs...