Uworld NCLEX Notes PDF

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Child Health CARDIAC All congenital heart defects**  Defects with increased pulmonary blood flow: o Atrial septal defect (ASD)  Abnormal opening between the atria that causes an increased flow of oxygenated blood into the R side of heart  Leads to R atrial & ventricle enlargement  Can be asymptomatic or may develop HF  S/S of decreased CO may be present  Surgical repair needed o Patent ductus arteriosus  Failure of the fetal ductus arteriosus to close within the first weeks of life  Machinery like murmur*  Can be asymptomatic or may develop HF  S/S of decreased CO may be present  Widened pulse pressure & bounding pulses are present  Treatment  Indomethacin  Used to close the ductus in premature infants or some newborns  Or surgical repair o Ventricular septal defect (VSD)  Abnormal opening between the R and L ventricles  Many VSDs will close spontaneously during the first year of life in children with small or moderate defects*  A characteristic murmur is heard*  S/S of HF & decreased CO are common  Obstructive defects: o Aortic stenosis  Narrowing or stricture of the aortic valve, causing resistance to blood flow from L ventricle into the aorta  Resulting in decreased CO, L ventricular hypertrophy, and pulmonary vascular congestion  Children show signs of:  Activity intolerance  Chest pain  Dizziness when standing for long periods  A characteristic murmur is heard*  Surgical repair needed o Coarctation of the aorta  Localized narrowing near the insertion of the ductus arteriosus  Blood pressure is higher in the upper extremities, than in the lower extremities*  Bounding pulses in the arms, w/ weak or absent femoral pulses  Cool lower extremities may be present  S/S of HF & decreased CO are common

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Children may experience: ALL RESULTING FROM HTN Headaches Dizziness Fainting Epistaxis  Surgical repair needed o Pulmonary stenosis  Narrowing at the entrance to the pulmonary artery  Resistance to blood flow causes R ventricular hypertrophy & decreased pulmonary blood flow  Can lead to pulmonary atresia --> no blood flow to lungs  A characteristic murmur is heard*  May be asymptomatic  Newborns with severe narrowing are cyanotic**  If severe enough, HF occurs  Surgical repair needed Defects with decreased pulmonary blood flow: o Tetralogy of Fallot  Includes 4 defects:  Ventricular septal defect  Pulmonary stenosis  Overriding aorta  Right ventricular hypertrophy  Pulmonary vascular resistance > systemic resistance  Shunt is from R to L  Pulmonary vascular resistance < systemic resistance  Shunt is from L to R  Diaphoresis during feeding indicates overexertion and respiratory distress  Infant may be developing HF  S/S:  Characteristic heart murmur  Palpable thrill on L lower sternal border  Tet spells  Hyper-cyanotic episode  Crying, feeding, and becoming upset may induce this*  Treatment:  Place the infant in the knee-chest position  Provides release of dyspnea as this angle improves oxygenation by reducing the volume of blood that is shunted through the overriding aorta and the ventricular septal defect  Morphine may be considered if dyspnea is not relieved  If O2 sat remains low, O2 may be indicated  Home interventions to reduce the incidence of tet spells include:  Providing a calm environment  Soothing & quieting the infant when crying or distressed  Offering a pacifier    

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Swaddling or holding the infant during procedures or times of stress  Providing frequent smaller feedings to reduce frustration due to hunger and limit sucking fatigue  Surgical repair is needed Kawasaki's Disease o Inflammation of arterial walls (vasculitis)  Coronary arteries can be affected --> can lead to coronary aneurysms o Unknown etiology o No diagnostic test o NOT contagious* o 3 phases:  Acute  Child is VERY irritable  Can last up to 2 months after the child is in remission  Red swollen hands & feet  Subacute  Skin peels  Convalescent  Child's temperament returns to normal o Treatment:  IVIG  Monitor for S/S of HF  Aspirin o Monitor for fever when DC home* Murmurs o Loud machine like systolic and diastolic murmur --> patent ductus arteriosus o Harsh systolic murmur --> ventricular septal defect o Diastolic murmur --> mitral stenosis and aortic regurgitation o Systolic ejection murmur --> pulmonic stenosis Infant CPR o Pulse assessment --> brachial artery  Preferred in infants d/t being easily palpable and close to the surface  Femoral pulse may be used for all clients, but not easily palpable on children d/t diapers and clothing  Carotid pulse is difficult to assess d/t child's shorter neck  Recommended for children >1 year old L --> R sided heart shunt o Higher pressure left side of heart to lower pressure right side of heart INCREASES PULMONARY BLOOD FLOW  Causes:  Patent ductus arteriosus  Atrial septal defect  Ventricular septal defect o Results in pulmonary congestion  Causing increased work of breathing and decreased lung compliance o S/S:

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Heart murmur Tachypnea Tachycardia Diaphoresis during feeding or exertion Heart failure Increased metabolic rate with poor weight gain

RESPIRATORY  Asthma exacerbation o S/S:  Wheezing  The absence of wheezes may indicate resolution of the attack or progression of airway swelling to the point of little air flowing through the lungs  Chest tightness  Dyspnea  Cough  Earliest sign*  May be nocturnal, dry, or productive  Retractions o Associated lung sounds  Make sure to understand epiglottitis & cystic fibrosis  Cystic fibrosis o Autosomal recessive disorder o THICKENED SECRETIONS d/t impaired chloride and sodium channel regulation that causes exocrine gland dysfunction o Potential complications:  Pulmonary  Thick sputum --> results in frequent respiratory infections & sinusitis  Chronic hypoxemia  GI  Obstruction of the release of pancreatic enzymes --> leading to malabsorption of fat-soluble vitamins (A, E, D, K) and other nutritional deficiencies  These pts need high calorie foods & supplemental enzymes w/ meals  High calorie, high protein, high fat diet*  Enzymes need to be given within 30 min of eating all meals & snacks  Reproductive  Absence of vas deferens or thickened reproductive secretions leading to infertility  Sweat gland abnormalities:  Increased salt loss  Salt replacement may be needed*  Dehydration  Hyponatremia during times of significant perspiration Clinical illness Nasopharyngitis

Presentation 

Common etiologic agents Nasal congestion

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Rhinoviru

(common cold)

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Discharge Sneezing Cough Sore throat

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Influenza virus

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Coronavir us

Laryngotracheitis (croup)

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Epiglottitis

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 Upper respiratory tract symptoms followed by:  Hoarseness  Barking cough  Stridor  Respiratory distress

Parainflu enza virus

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Haemoph ilus influenzae

 Upper respiratory tract symptoms followed by:  Wheezing  Cough  Respiratory distress

Respirato ry syncytial virus

Sore throat Dysphagia Drooling Respiratory distress Sitting up & leaning forward

Bronchiolitis

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HEM/ONC  Hb levels & associated diet modifications for iron o Richest dietary sources of iron:  Meat  Poultry  Fish o Foods high in vitamin C (such as tomatoes, potatoes, strawberries, oranges) may boost absorption of iron  Hemophilia A o X-linked recessive bleeding disorder  Carrier females pass the defect on to males o S/S:  Abnormal bleeding  Epistaxis  Joint bleeding  Bruise easily  Normal platelet function* o Treatment:  Replacement of missing clotting factor  In this case, factor 8  Monitor for bleeding*  Monitor neurological status

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 Child is at risk for intercranial bleed  NO contact sports Complications of sickle cell o Splenic sequestration crisis:  Too many sickled cells get trapped in the spleen, causing splenomegaly  This is life threatening --> can lead to hypovolemic shock o New onset stroke

GU Nephrotic syndrome o Kidney disorder characterized by:  Massive proteinuria  Hypoalbuminemia  Hypoproteinemia  Edema o Goals of treatment:  Reduce excretion of urinary protein  Maintain protein free urine  Reduce edema  Prevent infection  Minimize complications o Diet: regular diet with NO added salt during remission; and complete sodium restriction during times of massive edema o S/S:  Weight gain  Periorbital & facial edema common in morning  Leg, ankle, labial, & scrotal edema  Decreased urine output  Urine dark & frothy  Ascites  Lethargy  Pallor o Treatment:  Corticosteroids  Immunosuppressants are possible  Diuretics are possible  Albumin is possible if severe edema is present o Parents should be educated about testing urine for protein*  Hemolytic-uremic syndrome o Thought to be associated with bacterial toxins, chemicals, & viruses that cause AKI in children o Occurs primarily in infants and children 6 months- 5y/o o Clinical features:  Acquired hemolytic anemia  Hb & Hct levels are decreased  Thrombocytopenia  Kidney injury  BUN & Creat are increased

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CNS symptoms  Seizures, stupor, coma o Other S/S:  Vomiting  Irritability  Lethargy  Marked pallor  Oliguria or anuria  Bruising  Petechiae  Jaundice  Bloody diarrhea o Treatment  Hemodialysis or peritoneal dialysis if child is anuric  Strict I/O monitoring  Prevent infection  Provide adequate nutrition  Treatment of severe anemia Complications of glomerulonephritis o Severe HTN* o Hypertensive encephalopathy o Kidney failure o Pulmonary edema o HF o Seizures ENDOCRINE  Phenylketonuria (PKU) o Autosomal recessive disorder o Results in CNS damage from toxic levels of phenylalanine (amino acid) in the blood*  >20 mg/dL  Normal: 0-2 mg/dL o All newborns are screened for this! o Assessment:  In all children:  Digestive problems & vomiting  Seizures  Musty odor of urine  Mental retardation  In older children:  Eczema  Hypertonia  Hypopigmentation  Hyperactive behavior o Treatment:  Restrict phenylalanine intake*  Such as high protein foods (meat & dairy products) and aspartame

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 Monitor development  Educate pts about importance of diet & which foods contain phenylalanine Hypothyroidism in infants o Initially normal @ birth, symptoms develop after maternal T4 wanes o If left untreated, it can cause a severe intellectual disability* o S/S:  Lethargy  Enlarged fontanelle  Protruding tongue  Umbilical hernia  Poor feeding  Constipation  Dry skin  Jaundice o Dx:  Increased TSH  Decreased T4  Newborn screening o Tx:  Levothyroxine MUSCULOSKELETAL/INTEGUMENTARY  Pavlik harness o Used for developmental hip dysplasia o Maintains flexion, abduction, and external rotation o Worn continuously until hip is stable in about 3-6 months o Straps are assessed every 1-2 weeks by the HCP & adjusted if necessary  Parents should NOT alter the strap placement** o Care of infant wearing harness:  Assess skin 2-3 times daily for redness or breakdown  Dress the child in a shirt and knee socks UNDER the harness  Apply diapers underneath the straps to keep the harness clean  Leave the harness on at all times, unless otherwise indicated by the HCP*  Atopic dermatitis o Aka Eczema o Associated with family hx of the disorder, allergies, asthma, and allergic rhinitis o Goals:  Relieve pruritus  Lubricate the skin  Reduce inflammation  Prevent or control secondary infection o Assessment:  Redness  Scaling  Itching  Minute papules & vesicles  Weeping, oozing, & crusting of lesions

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Lesions can occur on:  Infants: scalp & face  Creases of elbows & knees, neck, wrists, ankles, or between the buttocks & legs

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Treatment:  Baths & moisturizers are important  Ex. Petroleum jelly  Topical medications should be applied within 3 min after bath  Antihistamines or corticosteroids  Antibiotics for secondary infections  PREVENT ITCHING  Wash clothing with mild detergent Duchenne muscular dystrophy o X-linked recessive disorder o Disease onset is 2-5 y/o o Muscles of the proximal lower extremities and pelvis are affected first o No cure! o Most children are wheelchair bound by adolescence and die by 20-30 y/o d/t respiratory failure o S/S  Gower sign  Use of one's hands to rise from a squat or from a chair to compensate for proximal muscle weakness  Calf pseudohypertrophy  Thigh atropy

NEURO/SENSORY  Bacterial meningitis o S/S in infants an increased ICP  Need to monitor fontanels for any bulging  They are early indicators of increased ICP in children  "Sunset eyes" o Sclera visible above the iris o Common sign of increased ICP in children  Myopia vs hyperopia o Myopia: nearsightedness

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Reduced visual acuity when viewing objects at a distance S/S:  May hold objects near their face or sit near objects to see clearly  Squinting their eyes o Hyperopia: farsightedness Strabismus o Crossed eyes o Disorder involving misalignment of the eyes d/t congenital defect or acquired weakness of an eye muscle o If left untreated by age 4-6, permanent reduction or loss of visual acuity in the affected eye can occur Retinoblastoma o A unilateral or bilateral retinal tumor o The most common childhood intraocular malignancy o It is typically diagnosed in children under age 2 o Usually first recognized when parents report a white "glow" of the pupil (leukocoria)  Light reflecting off the tumor will cause the pupil to appear white instead of displaying the usual red reflex

GROWTH & DEVELOPMENT  Thumb sucking & teeth misalignment  Typically, infants display head lag (ie, head falling behind the shoulders when raised from a supine to a sitting position) from birth through age 4-6 months. o Head lag remaining after age 6 months is an abnormal finding often associated with cerebral palsy or autism  Marfan Syndrome: o Aortic root disease (ie, aneurysm, dissection) is the major cause of morbidity and mortality in Marfan syndrome.  Therefore, competitive or contact sports are discouraged due to the risk of cardiac injury and sudden death  The posterior fontanelle fuses by age 2 months, and the anterior fontanelle fuses by age 18 months  Birth weight doubling by age 6 months and tripling by age 12 months  Pincer grasp o Develops between 8-10 months  Hearing impairment in children o Commonly have monotone voice or speak very loudly o They are shy & timid o Withdrawn from socializing  Lead poisoning can lead to many severe complications of the neurological system (eg, developmental delays, cognitive impairment, seizures) o Elevated blood lead levels are particularly dangerous in young children due to immature development of the brain and nervous system  Puberty in boys o First sign: testicular enlargement  Occurs between 9 1/2-14 y/o

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Mammary gland enlargement, non-purulent vaginal discharge (leukorrhea), and mild uterine withdrawal bleeding (pseudomenstruation) are benign transient findings commonly seen in newborns o These are physiologic responses to transplacental maternal estrogen exposure  Reassurance should be provided  Monitoring the amount, color, and consistency is the appropriate action PLAY stages*

Celiac Disease o NO GLUTEN! o BROW  Barley  Rye  Oats  Wheat o Cannot have soy sauce either o Rice, corn, & potatoes are allowed Esophageal atresia & Tracheoesophageal fistula o Most common S/S:  Frothy saliva  Coughing  Choking & cyanosis during feeding*  Drooling o High risk for aspiration o The upper esophagus ends in a blind pouch and the lower esophagus connects to the primary bronchus or the trachea through a small fistula o EA/TEF can usually be corrected with surgery o Plan of care:  Maintain NPO status  Positioning the client in supine @ 30 degrees  Keeping suction set available next to bed Iron deficiency anemia o Most common chronic nutritional disorder in children o Causes:  Insufficient dietary intake  Premature birth  Delayed introduction of solid food  Over consumption of cows milk before 1 year*  >24oz per day Intussusception o A contrast enema is used for diagnostic purposes and often reduces the intussusceptions  An air enema is considered safer than a barium enema** Pyloric stenosis o Metabolic alkalosis o Hypokalemia

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o Elevated Hct d/t dehydration* The introduction of solid foods generally occurs at age 4-6 months o When introducing new foods, parents should allow several (eg, 4-7) days between each new food to observe for any reactions to a specific food.  Allergic responses often worsen with subsequent exposure, so it is a priority to identify food allergies early o At age 6-8 months, an infant can try pureed fruits & veggies, followed by simple finger foods PKU* Honey is not recommended in children under 12 months old d/t risk for botulism

INFECTIOUS DISEASE  Trismus: the inability to open the mouth d/t a tonic contraction of the muscles used for chewing o Indicates a PROBLEM, requiring intervention!  Reye syndrome o Often developed after having a recent viral infection, especially influenza or chicken pox  Live vaccines (Varicella & MMR) should be delayed for 11 months after IVIG administration  Hemophilia o High risk of bleeding  Avoid aspirin  Avoid IM injections  SQ is preferred  Fifth disease ("slapped face")

MATERNAL HEALTH 

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ANTEPARTUM Physiologic decreases in systemic vascular resistance during pregnancy cause a steady, slight decrease in blood pressure (BP) beginning in the first trimester and reaching the lowest point around 24-32 weeks gestation o In the third trimester, BP gradually returns to pre-pregnancy baseline* o An increase in BP of ≥30 mm Hg systolic or ≥15 mm Hg diastolic over pre/earlypregnancy measurements, even in the absence of hypertension (ie, ≥140/90 mm Hg), is a deviation from normal physiologic BP responses in pregnancy  Requires further assessment for other signs/symptoms (eg, proteinuria, headache, right upper quadrant pain) NSAIDs must be avoided during the third trimester due to the risk of causing premature closure of the ductus arteriosus in the fetus o Can be taken in the 1st & 2nd if benefit outweighs risk o Acetaminophen can be used throughout pregnancy as an alternative  Don’t exceed 4g per day Intrahepatic cholestasis of pregnancy o A liver disorder exclusive to pregnancy that manifests with intense, generalized itching but no rash  Itching often involves the hands and feet and worsens at night o This condition increases the risk of intrauterine fetal demise and requires priority assessment by the health care provider Weight gain during pregnancy

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Syphilis o Can pass through placenta and cause teratogenic effects on fetus o Treatment prenatally: IM penicillin  If penicillin allergy, they may require penicillin desensitization so that adequate treatment can be provided Decreased fetal movement = potential warning sign of fetal compromise Preterm birth risk factors: o Hx of preterm birth o Previous cervical surgery o Tobacco or other drug use o Infection  Periodontal  UTI o Maternal age  35 o Maternal undernutrition o Non-Hispanic black women Intra-abdominal bleeding can lead to referred shoulder pain o Such as in ruptured ectopic pregnancy HELLP syndrome o Severe form of pre-eclampsia o Hemolysis, elevated liver enzymes, and low platelet count o S/S:  RUQ pain  N/V  Malaise Fetal tachycardia is a baseline of >160 beats/min for >10 minutes Oligohydramnios vs polyhydramnios Angiotensin-converting enzyme (ACE) i...