PediatricsTerm Review

Cystic Fibrosis

• Chronically ill children with respiratory issues-Frequent chronic infections

• Thick mucous secretions• Absorption issues• Shortened life

expectancy- America 37.4 years

• Anglosaxon children• Need lung transplant

Cerebral Palsey

• Caused by damage to motor control center of the brain while it is developing

• Causes motor issues, visual impairments

• No cure

• High prevalence of epilepsy

• Lifetime of physical therapy to maintain optimal function

Sickle Cell Anemia

• Genetic adaptation to malaria

• Primarily affects African American’s

• Affected children have episodes of severe pain

• Require surgery to insert port and often remove spleen

• These children are very sick and in a lot of pain

Crohns Disease

• Inflammatory disorder affecting entire GI tract

• Abd pain

• Bloody stool

• Trouble with nutrition

• Often require colostomy

Crohn’s Disease

• Bowel is attached to abdominal wall creating a “stoma” so that feces can pass freely into a collection bag

Asthma• Chronic inflammatory

disease causing a narrowing of the lower airways

• This narrowing causes wheezing or whistling sound

• http://www.youtube.com/watch?v=-S8T2JhMrYM

• http://www.youtube.com/watch?v=9S_WwaXY1eE

Croup

• Acute inflammation of upper airways causing a narrowing of the airway. One of the concerns is epiglottitis which is inflammation of the upper airway.

• Viral cause

• Produces barky cough or stridor

• Sudden onset, usually at night

• Children usually grows out of this condition

http://www.youtube.com/watch?v=Qbn1Zw5CTbA

RSV

• Respiratory SyncytialVirus

• Affects the lungs and respiratory system of neonates, especially premature infants

• Highly contagious

• Prevention=hand washing and vaccination of at risk infants

PICC Lines (Vascular Access Device)

• Peripherally inserted central catheter• Form of IV access or (vascular access

device) that can be used for a prolonged period of time

• Benefits: – Medications can burn when

administered and this administration system avoids that complication.

– Avoid frequent needle sticks for blood.– Can be used for giving blood and

chemotherapy

• Risks:-Infection

Lumbar Puncture• Catheter inserted into

subarachnoid space to retrieve Cerebrospinal fluid for testing

• Fluid should be clear and free from particulate matter

• Can be mildly uncomfortable

• Testing for meningitis and other disorders that aftectthe central nervous system

Pre Transplant Considerations

• High risk for infection

• Child is very sick and considered unstable

Acute Myeloid LeukemiaAcute Lymphoblastic Leukemia

• ALL & AML start from immature blood stem cells (white blood cells) in the bone marrow and progress into the blood stream ultimately affecting lymph nodes, liver, spleen, ect.

• If not treated quickly, can be fatal in just a few months

Solid Organ Tumors

• Tumor is abnormal growth of cells

• Requires removal of organ, tumor, chemo, radiation to treat

Bone Marrow Aspiration/Biopsy

• Painful procedure to retrieve bone marrow

• Bone marrow is tested for cancer cells

Common Medications

• Antibodies- given to boost immunity

• Interlukin- given to help boost immunity

• Ketamine- given for sedation

Skills Checklist Review

• Patient and family teaching is integral for a patients success. Nurses are responsible for preparing a patient for discharge and home care. The learning process should start immediately. Nurses are also responsible for reinforcing pre-op and post-op considerations so that the patient knows what to expect.

• Recognition of abuse and neglect with appropriate reporting is important. Nurse are mandatory reporters and if they fail to report known or suspected abuse they can be held liable in court for failing to advocate for the abused child.

Head to Toe Assessment

• Nurses are required to do a head to toe assessment once per shift. This includes listening to heart sounds, breath sounds, GI sounds, checking for edema, and mental status.

• The nurse should be able to identify abnormalities based on their assessment and determine if this is a change from baseline and reportable to the doctor.

Cardiovascular Assessment

• When assessing the cardiac system, the nurse should listen to heart sounds, note the rate, and check for over all circulatory status.

• To check the over all status of a patient the nurse should look at the patients overall color. (Is the patient warm dry and pink?)

• Capillary refill is checked by squeezing the tip of a patient’s finger. When the finger is squeezed the color will blanch. Within 3 seconds of releasing the squeeze, the patients finger should turn back to its normal coloring. If the finger stays blanched longer the 3 seconds there could be a circulatory issue.

Cardiovascular Assessment Disease Processes

• Cardiopulmonary Arrest- the heart stops beating or is beating too slow to maintain circulation and “ACLS” must begin to keep patient alive.

• CHF- Congestive Heart Failure is a condition where the cardiac muscle is weakened and cannot pump blood through the body effectively. The blood can back up in the lower legs and the lungs making it difficulty for a patient to breath. One of the ways this is treated is to give patient’s medication that will remove the excess fluid from the patient’s body that in turn, decreases the workload of the heart.

• Congenital Heart defects- There are a variety of congenital heart defects. Congenital means that the condition was present from birth. Depending on what the defect is will determine the nursing care.

Cardiac Monitoring

• EKG monitoring- and EKG is a picture of the electrical activity of the heart. This picture can tell the cardiologist exactly which part of the heart is malfunctioning and can diagnose many different cardiac disorders. Nurses should be able to differentiate basic deviations from normal in order to initiate prompt intervention if necessary.

• Vital Sign Monitoring- I would expect all applicants to have a 4/4 proficiency in this area. This is a basic function of nursing and should be second nature to our applicants.

Pulmonary

• Adventitious Breath Sounds- Are abnormal lung sounds and can indicate a disease process such as asthma or CHF.

• Nasal Flaring/Oxygenation Status/Rate and Work of Breathing- is a condition present where a child is having difficulty breathing. In a health child, the diaphragm moves to assist with breathing. Children with respiratory conditions often use other muscles to assist with their breathing including flaring of the nose and sternal retractions. Sometimes children will position themselves “tripod” in a manner that will help them to breath more efficiently when their airway is constricted.

Pulmonary

• Airway Obstruction- If the airway is blocked it is called obstructed. There are a variety of causes of airway obstruction including asthma, aspiration of a foreign body, anaphylaxis.

Tuberculosis• A condition caused by inhalation of

a bacteria that causes respiratory symptoms including cough lasting longer than 3 weeks, night sweats, weight loss, and bloody sputum.

• Very contagious and very difficulty to treat.

• Treatment usually consists of at least two kinds of antibiotics that have to be taken religiously for at least 6 months.

• Can cause irreversible lung scarring.

Pulmonary Monitoring

• Pulse Oximetry- a sensor that is put on a finger, toe, ear, or even the forehead that measures the amount of oxygen that is circulating in a patients body.

• Apnea- the absence of breathing. The concern is if this happens at night the patient could die in their sleep. Premature babies and those that are considered high risk are often placed on an apnea monitor that will alarm if there has been no inhalations in a specified amount of time.

Neurology

• Glascow Coma Scale- A standardized assessment tool that measures a patients orientation status. The higher the score the more alert and awake the person is. Patients that have lower scores tend to have poorer outcomes.

• Neurological Assessment- one of the first areas that declines in a patient is their neurological status. Children with suspected brain trauma or other issues require frequent neuro checks to promptly identify issues. Typically neuro checks are done on all patients once per shift. If the patient is at risk for neuro injury, neuro checks can be required every 15 minutes.

Neurological

• Febrile Seizure- Children often present to the ER after experiencing a febrile seizure. These are common in children and are preventable with antipyretic medication such as tylenoland motrin. There is usually no lasting harm from one of these events and they are very different in nature from a true ‘epileptic’ seizure. They can be scary to observe.

Neurological

• Head injury- require neurochecks to identify decline

• Meningitis- infection and or inflammation of the meningies in the brain causes by bacteria or virus. Diagnosed via lumbar puncture. The patient is usually very sick but usually recovers without any deficits if treated aggressively.

Spina Bifida

• A congenital condition where a portion of the spine and spinal nerves grow outside of the patients spinal canal in a small sac.

• This is completely preventable through maternal nutrition. Folic Acid.

• Can cause a varying degree of disability depending on how many and how pronounce the protruding nerves are.

• Some children experience lower motor function disability and problems with bowel and bladder control.

Gastro Intestinal Assessment (GI)

• GI Assessment with bowel sounds- Bowel sounds should be present when auscultating the abdomen. The bowel sounds should not be too fast or too slow and should be the correct pitch. Any deviation from normal can indicate an abnormal disease process.

• Colostomy Care- should be performed regularly and is often done by the patient. The patient should be encouraged to participate in the maintenance and care of the “stoma” (the bowel opening). The soiled bag is removed and the skin is cleaned and prepped for reapplication of the bag “appliance.”

GI Assessment

• Nutritional Status- Can be determined just by looking at a patient. Can also be determined by labs.

• Anorexia is a condition where the patient refuses to eat an appropriate amount of calories in the effort to be in control of their weight. They see themselves as overweight and have very low self esteem. They use food as an environmental factor that they can control. Considerations for these patients include psychiatric care to address underlying body issues. These patients are at risk for bone fractures and cardiac arrhythmias due to their poor nutritional intake.

GI Assessment• Bulimia- is a condition where the

patient believes that they are over weight and attempts to influence this by over eating and then inducing vomiting or using laxatives to purge the ingested food. (Binging and purging)

• These patients have underlying psychological disorders similar to anorexia and must have therapy as part of their medical care to correct underlying psych issues.

• Patients that have bulimia often use the bathroom immediately after eating to purge the food they just ingested. They tend to have esophageal scarring and often scarring on their hands from where vomiting has been induced. They tend to have many dental carries as the stomach acid from the frequent vomiting erodes the enamel on their teeth.

GI Assessment

• Failure to thrive- is a diagnosis most often given to premature babies and older adults.

• It means that there is a nutritional deficit of some cause, either because of lack of intake or absorption problems.

• These patients are underweight and usually appear cachectic.

GI Assessment

• Ingestion/drug overdose- any patient presenting after ingesting a substance, drug, or chemical is usually placed on a 51-50 hold until it is clear that it was accidental and not intentional.

• Immediately call poison control.

• Charcoal is generally given to absorb the chemical in the stomach.

GI Assessment

• Liver Failure- the liver is responsible for processing drugs and detoxifying the body from harmful substances in addition to producing enzymes needed for digestion and affecting clotting times.

• Patients that have liver failure are at risk for bleeding and can become delirious because of the build up of toxins in the body.

• The liver often swells and these patients often look pregnant due to the distended abd.

• The sclera “whites of the eyes” turns a yellow color.

• The nurse should assess the patients lab work including LFT’s (Liver Function Tests) that include various markers for this condition. These tests include serum ammonia and amylase.

Genitourinary

• Fluid status of an individual is assessed by looking at the mucous membranes and skin turgor. The most accurate measurement of hydration status is blood work.

• When the skin on the back of a patients hand is pinched, it should immediately return to a normal shape and not stay raised. This is called tenting and is an indication of dehydration.

Genitourinary

• Acute/Chronic Renal Failure- condition where the kidney’s ability to filter blood and control waste excretion process through urine is impaired.

• Unfiltered toxins and excess water builds up in body causing stress on various organs including heart.

• Dialysis is required to filter blood when kidneys are unable. Sometimes kidney transplant is necessary to promote long term wellness.

• This process of the body self regulating the amount of water it retains is considered fluid balance.

Genitourinary

• Urinary Tract/Bladder Infection- is a condition where bacteria, generally from anal area makes its way into urethra and or bladder. If untreated can lead to kidney infection.

• Symptoms are painful, frequent urination with little urine produced. Feeling like bladder is full even after voiding and having a feeling of urgency.

• More common in women because urethral opening is closer to anus than in a man.

• Very common in young children. • Treatable with antibiotics • To diagnose, a urine specimen is collected

either by cleaning the perineal area and voiding into a sterile specimen cup or via catheter to retrieve urine directly from the bladder.

Genitourinary

• The measurement of I & O (Intake and Output)- any fluid that is ingested or infused into the body is counted as well as the amount of urine, surgical drains, emesis (vomit) ect. that comes out.

• BUN and Creatinine are measurements of kidney function.

• Serum Electrolytes are used to measure overall hydration status. These values include sodium, potassium, calcium, magnesium. If they are too high or too low the plan of care may include giving supplements or medications to remove them from the body.

Genitourinary

• Diaper weights- Children in diapers are unable to void in a collection device. To measure I&O on these patients, a clean diaper is weighed, and the soiled diaper is weighed. The difference is subtracted and converted from grams to mLs using a conversion tool. http://calculator-converter.com/converter_g_to_ml_grams_to_milliliters_calculator.php

Endocrine Assessment

• Diabetes- is a condition where the body attempts to neutralize the amount of sugar that is circulating in the body at a given time.

• People who are diabetic lack the ability to produce their own insulin or fail to produce enough insulin and must have this supplemented via injections.

• Sugar in the blood can cause devastating effects on the human body. It can delay healing or wounds and can harm the kidneys and eyes. People with diabetes have loss of sensation in their feet and often have wounds that they are unaware of simply because they cannot feel them.

• Diabetes symptoms are managed through diet and medication. This is not a condition that can be cured.

Endocrine

• Diabetic Ketoacidosis is a condition where the blood sugar is extremely high. This alters the patients body chemistry in a way where there is break down of healthy tissues. This can lead to death if not treated.

• Can occur in children that have not yet been diagnosed with diabetes.

• Blood sugar can be checked by a finger stick or from serum electrolyte lab work.

Endocrine

• Circulation checks are performed by checking the pulse in the affected limb. Part of this assessment can also include capillary refill check. (see previous cardiovascular slide.)

• Sometimes the pulse is marked with an X so that it can easily be found a second time by the primary nurse and/or other health care workers

Musculoskeletal

• Muscular Dystrophy- a condition where all of the muscles in the body are weakened including the heart and respiratory muscles.

• There is no cure

Musculoskeletal

• Cast Care- Casts cannot get wet and must be covered with plastic when showering. Even excessive sweating can be enough moisture to cause mildew, mold or other infections to cause harm to the covered skin.

• You should never use an object to scratch underneath the cast.

• It is important to keep the cast elevated to keep swelling at a minimum.

• If there was a great decrease in the amount of swelling under the cast, and it is now rubbing against the skin, the patient may need a new cast applied that fits more appropriately.

Crutch Walking

• It is important that the crutches are fitted specifically for the patient.

• The patient should not rest arm pits on the top of the crutches. Doing so can damage the brachial nerves. The patient should use their arm strength to avoid leaning too heavily on the crutches.

• http://www.youtube.com/watch?v=pYzUQb79_Rw

Spica Cast

• A spica cast (also called a hip spica cast or body cast) immobilizes the hips and thighs so that bones or tendons can heal properly. It's usually put on in surgery while the child is sleeping.

• There are several types of spica casts. They begin at the chest and may extend down to cover one leg, both legs, or the leg on one side and down to the hip or knee of the other side. The doctor will decide what type of spicacast your child needs.

Blood Transfusions

• Require two licensed caregivers verify that the appropriate blood is given to the appropriate patient.

• High risk for reaction to the blood that increases with each transfusion. Chronically ill patients that have had multiple transfusions in the past are at the highest risk for complication.

Hemophilia

• Patient lacks a clotting factor in their blood that causes them to be unable to stop bleeding.

• Varying degrees of severity.• Concern for internal injuries

because blood is not apparently visualized as with an open wound.

• Clotting factor replaced intravenously.

• Genetic in origin, no cure, mostly in boys, very very veryrare in females

HIV/AIDS

• Patient has no/ weakendimmune system to respond to infections.

• As a result, patients can contract rare conditions that are extremely rare in health individuals.

• Reverse isolation precautions-where healthcare workers wear gowns and masks to avoid infecting the patient rather than wearing the protective equipment for fear that patient will infect them.

• High incidence of cancer, tuberculosis, pneumonia.

Anaphylactic Shock

• Condition in which patient’s immune response is triggered causing a swelling of the airway, sharp drop in blood pressure and hives with itching.

• The concern in these patients is that the airway will close and the patient will not be able to breathe.

• Generally, anaphylaxis doesn’t happen on the first exposure to the allergen but rather on subsequent exposures. (The patient may have been on lisinopril for 10 years but present with angioedema (swelling) after taking a regularly scheduled dose.)

• Common causes of anaphylaxis in children are:– Peanuts – Bee Stings– Penicillin– Eggs– Honey

Wound/Integumentary Assessment• Signs and symptoms of

infection:

– Redness

– Green/yellowish drainage

– Pain and swelling

– Foul odor

Assessment of Burns

• Very painful!!!• High risk of infection• Must have tissue cleaned

out to avoid scarring that will limit mobility after the wound has healed.

Bladder Irrigation

• Bladder is irrigated with normal saline to remove blood clots after bladder surgery.

• I have only performed this procedure on older men that have prostate issues or have had recent bladder surgery. I briefly researched this procedure in children and did not readily find explanation.

Medication Delivery

A. IM Medications- Given intramuscularly in approve sites depending on the medication. Allows for slower absorption of the drug. Ex. Vaccinations, antibiotics, pain medication.

B. SQ- Subcutaneous is just under the skin in fatty areas including abd, inner thigh and back of arm. Ex. Insulin.

C. NG- Nasogastric tube- for patients that are unable to swallow medications on their own. This tube is inserted in the nose and extends down to the stomach.

• NG tube insertion is confirmed with chest x-ray, instillation of air while listening to stomach, and aspiration of gastric contents.

C

C

B

A

Medication Delivery

• PO- is Latin for by mouth

A. Rectal Medications-“suppositories” for patients that are vomiting and have no IV access.

B & C. Needleless systems-RMCSJ is a needleless system. Medications come in a variety of packaging. A needle or other device is required to draw up the medication from the vial and into the delivery syringe (C). Figure B is a lure lock syringe that can be twisted on to a hub.

A

C

B

IV Therapy

• An arm board is used in pediatric and sometimes adult settings to maintain and IV.

• Tape or gauze is often applied to secure the IV in place and ensure that it doesn’t intentionally or inadvertently get pulled out.

Adverse Reactions

• Can occur if the medication is delivered outside of the vein

• Medication can be caustic to the vein• If IV was misplaced, it should be reinserted• If medication is caustic to vein, nurse can

slow infusion down or use warm compress over site to ease pain of administration.

• Some medications are extremely toxic and if they do not go directly into vein and get into the surrounding tissue, complications and skin death can occur. (VERY RARE)

• Common symptoms can include:– Pain– Redness– Swelling– Warm or cold area around IV site

IV EquipmentA. Heparin or Saline LockB. Infusion Pump- Generally used for children

and adults. The machine is programmed to deliver the appropriate rate/dosage of medication.

C. Syringe pump- used for infants and children that only need a small amount or more concentrated medication delivered. Syringe with medication is attached directly to tubing and placed in the machine rather than a full bag of medication or fluid.

D. PCA pump- Patient controlled analgesia, locked medication delivery system with a button that the patient can press when they feel like they need additional pain medication. The frequency and dosage is programmed into the machine to avoid over dosage. The idea behind the self administration is that pain can be controlled via the patient and that the lowest amount of medication is delivered as possible to maintain comfort.

A

BC

D

Scalp Vein• Difficult to insert a peripheral line

in children due to small veins and lost of subcutaneous fat.

• Scalp vein is a good choice because of its close proximity to the surface, minimal subcutaneous fat and less movement and the lack of a flexible joint

• This reduces the likelihood of dislodging the catheter, which is common with intravenous catheters placed in the arms or legs.

Intraosseous Infusion

• IO infusion- Catheter inserted into bone.

• Usually inserted during emergency situations when there is no IV access available.

Oxygen Delivery Devices

A. Ambu-bag

B. Nasal Cannula

C. Non-Rebreather Mask

D. Portable Oxygen

E. Venti Mask

AB

C

D

E

Oxygen Administration

• Nebulizer Treatments-Broncho-dilator such as Albuterol is nebulized and inhaled to open air ways and assist with breathing.

• Tracheostomy- Surgical opening of airway if throat is closed due to inflammation or foreign body blockage. Some patients have trachs for life due to anatomical considerations.

Assisted Airway

• Intubation-Process of inserting a tube into a patient’s airway to assist with breathing. Usually inserted in the field or ER.

• Extubation- Process of removing the tube that has been assisting with breathing. Usually removed in the ICU.

Isolette

• Isolette- to keep infants at the appropriate temperature, protected from infection, and to provide photo therapy. Used in NICU.

• Phototherapy- used to break up excess bilirubin that collects in the premature infants body. Eyes must be shielded to prevent damage to retina.

PEG Tube

• Tube that is surgically inserted into through abdominal wall into stomach to give nutrition and medications to. This is a more long term solution than an NG tube. Given to patients that are unable to swallow or in a vegetative state ect.

Nutritional Therapy

• TPN and Hyperalimentation- Total nutrition given via IV though PICC or Central Line

• Tube Feeding Pumps- Special pump used for PEG tube feedings. Generally, patients have continuous feedings 24 hours a day to maintain nutritional status and blood sugar levels.

• When a patient is received tube feedings, the head of the bed should not be lower than 30 degrees to avoid the possibility of aspiration

Pain Management

• Moderate sedation for procedures such as:

– Bone dislocation or fracture

• Ramsey Scale- Standardized scoring tool that rates level of sedation

• Chest Physiotherapy- to assist with the clearing of secretions for cystic fibrosis children. http://www.youtube.com/watch?v=B8wTlqhuSpc

Chest Tube• Chest Tube Drainage System- generally chest

tubes are inserted in the ER after chest trauma from MVC or other accident due to a collapsed lung.

• Nurses must assess the amount of drainage that collects during their shift and maintain the sterility of the collection unit.

Other Equipment

• Doppler- Used to check blood flow in an extremity. Also used to detect a heart beat in a pregnant mother who is greater than 20 weeks gestation.

• Hyper/Hypothermia Blanket- used to cool or heat a patient who’s temperature is far outside normal limits.

The End

• Questions