Pediatric Nursing Edison O. Dangkeo,rn

Pedia

COMPREHENSIVE LECTURE ON PEDIATRIC NURSING PART 1. GROWTH AND DEVELOPMENT

• •

GROWTH- in physical size of a structure or whole (Quantitative) 2 PARAMETERS • WEIGHT- most sensitive • Birth weight: 2X by 6 mos 3x by 1 yr 4X by 2-2½ yrs • LENGTH/HEIGHT

• • • •

• •

•

•

• •

• • • • • • •

•

1 inch/mo. In 1st 6 mos ½ inch/mo. At 7-12 mos Ave. in ht. during 1st yr is 50% Approx. ½ of adult ht. at 2 yrs

DEVELOPMENT- in the skills or capacity to function (Qualitative) How to Measure Development – by simply observing a child doing specific task – by noting parent’s description of the child’s progress – by DDST DDST 4 Main Rated Categories – Language – Personal-Social – Fine Motor Adaptive – Gross Motor Skills MATURATION- synonymous with development , also known as READINESS COGNITIVE DEVELOPMENT- is the ability to learn (to change behavior) and understand from experience, to acquire and retain knowledge, to respond to a new situation and to solve problems. Basis of Mental Retardation IQ= mental age X 100 chronological age 0-20 profound MR (infant) 20-35 severe (0-2 yo) 35-50 moderate (2-7 yo) trainable 50-70 mild (7-12 yo) educable 70-90 borderline 90-110 normal (average IQ) 130 gifted

BASIC DIVISIONS OF LIFE

• •

1st Stage- Prenatal (from conception to birth) 2nd Stage- Infancy

– – •

Neonatal: 1st 28 days of life Formal Infancy: 29th day to 1 yr

3rd Stage- Early Childhood – Toddler: 1-3 yrs 1 aoih0718

Pedia –

• •

Preschool: 4-6 yrs

th

4 Stage- Middle Childhood – School age: 7-12 yrs 5th Stage- Late Childhood – Preadolescent: 11-13 yrs – Adolescent: 12-18 yrs (or 21)

PRINCIPLES OF GROWTH AND DEVELOPMENT 1. Growth and development is a continuous process (from womb to tomb) 2. Not all parts of the body grow at the same time or at the same rate (Principle of Asynchronism) PATTERNS OF GROWTH AND DEVELOPMENT • Renal, GIT, Musculoskeletal, CVS- fairly, smoothly during childhood • CNS- rapidly at 1-2 yrs • Immune System- rapidly during infancy and childhood – tonsils: of adult proportion by 5 yrs • Reproductive System- rapidly during puberty RATES OF GROWTH AND DEVELOPMENT • Fetal and Infancy- most rapid • Toddler- slow • Preschool- alternating rapid and slow • School age- slower • Adolescent- rapid 1. •

• • • • • • • • • 4.

Each child is unique 2 Primary Factors – Heredity (Non-modifiable) or “Nature” Race Intelligence Sex Nationality – Environment (Modifiable) or “Nurture” Quality of Nutrition Socioeconomic status Health Ordinal position in the family Parent-child relationship Growth and Development occurs in a regular direction reflecting a definite and predictable patterns or trends

DIRECTIONAL TRENDS- occurs in a regular direction reflecting the development of neuromuscular functions: these apply to physical, mental, social and emotional developments



Cephalo – caudal: “ head to tail”. It occurs along body’s long axis in which control over head, mouth and eye movements and preceeds control over upper body torso and legs.



Proximo–distal: from center of the body to extremities e.g. baby uses whole arm in crawling then hand pincers

 

Symmetrical: each side of the body develop on the same direction at same time and rate Mass-Specific (Differentiation): the child learns from simple operations before complex functions or move from a broad general pattern of behavior to a more refined pattern. E.g. Crying infant suggests wet diaper, hunger, thirst or pain until can use words for milk etc. 2 aoih0718

Pedia SEQUENTIAL TRENDS- involves a predictable sequence of growth and development to which the child normally passes a. locomotion b. language and social skills SECULAR TRENDS-refers to the worldwide trend of maturing earlier and growing larger as compared to succeeding generations 5. BEHAVIOR is the most comprehensive indicator of developmental status. 6. PLAY is the universal language of the child. 7. A great deal of skill and behavior is learned by PRACTICE. 8. There is an optimum time for initiation of experience or learning. 9. Neonatal reflexes must be lost first before development can proceed. e.g. Spitting/extrusion reflex must be overcome before infant can be fed with solid foods REFLEXES- different involuntary reactions to specific forms of stimulation Importance: – For neonate’s survival e.g. feeding reflexes: rooting, sucking, swallowing protective reflexes: blink, gag, cough, Moro – Reflects how well CNS is functioning – Forms the basis for later, more sophisticated behavior A. Blink- rapid eyelid closure when strong light is shown, To protect the eyes, Disappears at death B. Palmar Grasp- when a solid object is placed in the palm, the baby will grasp the object – To cling to the mother for safety – Beginning ability to hold then release objects – Disappears at 6 wks to 3-4mos C. Step-in/Walk-in Place– neonate placed on a vertical position with their feet touching a hard surface will take few quick, alternating steps, Present at birth, Disappears at 1 mo * Placing– almost the same with step in place reflex only that you are touching the anterior surface of a newborn’s leg • Normal: flex hip and knee, place stimulated foot on top of the table • Abnormal: no response; consider paralysis if born breech • Disappears at 6 wks D. Plantar grasp– when an object touches the sole of a newborn’s foot at the base of the toes, the toes grasp in the same manner as the fingers do • Disappears at 8-9 mos in preparation for walking E. Tonic-neck/ Boxer/ Fencing- when newborn lie on their backs, the head turn to one side. The arm and the leg on the side to which the head turns extend, and the opposite arm and leg contract. • Disappears within 3-4 mos F. Moro/ Startle- test for neurological integrity • upon exposure to loud voice or jarring the crib, the baby will assume “letter C” position: throws arms forward and draws legs up • Abnormal- assymetrical response • To protect the baby from attacker • Present at 36 wks AOG • Disappears at 4-5 mos when baby can roll over G. Magnet– when there is pressure at the sole of the foot, the baby pushes back against the pressure H. Crossed extension- test for spinal nerve integrity; when sole of foot is stimulated by sharp object, that foot flexes and the other foot extends I. Trunk incurvation/ Galant- while in prone, when the paravertical area is stimulated, the trunk flexes and the pelvis swings towards the touch J. Landau- test for muscle tone; while in prone, with the examiner’s hands supporting the baby’s trunk, the baby exhibits some muscle tone • Abnormal: collapse of the baby in limp, concave position •

3 aoih0718

Pedia • Present at 3 mos K. Parachute reaction- while on ventral suspension, sudden change in equilibrium causes extension of arms and legs • Abnormal: collapse of the baby in limp, concave position • Present at 6-9 mos. L. Babinski- sole of foot stimulated by blunt object in inverted J causes fanning/ dorsiflexion of all toes • Abnormal: fanning of great toe only • Present due to immature CNS; myelinization is not yet complete • Disappears at 2 mos to 2 yrs THEORIES OF DEVELOPMENT • DEVELOPMENTAL TASK- a skill or growth responsibility arising at a particular time in the individual’s life. The successful achievement of which will provide a foundation for the accomplishments of the future tasks. PSYCHOSEXUAL THEORY • or Psychoanalytic Theory

• •

Sigmund Freud (1856-1939) – an Austrian neurologists, founder of psychoanalysis Libido (sexual energy) goes to one part of the body to another where it is responsible for survival

5 PHASES 1. ORAL- (0-18 mos) Infant  mouth- site of gratification  Activity: biting, sucking, crying (for enjoyment and release of tension)  Never discourage thumb sucking  Offer pacifier when NPO  ID- source of all drives; present at birth; striving for gratification of needs



EGO- for reality testing and problem solving, develops at 4-5 mos. When infant begins to see self separate from mother (development of sense of self)

2.  

ANAL-(18 mos- 3 yrs) Toddler anus- site of gratification where elimination takes place Principles in Toilet Training:  “Holding on”- child wins, becomes stubborn or antisocial  “Letting go”- mother wins, child becomes obedient, kind, perfectionist, obsessive-compulsive

3. 

PHALLIC-(3-6 yrs) Preschool genitalia- site of gratification



knowledge on 2 sexes , exhibitionism is normal  Accept child fondling his/her genitalia as normal area of exploration  Answer child’s questions directly SUPEREGO is a necessary part of socialization develops at 3-6 yrs; includes internalization of values, ideas and moral standards of parents and society; development of CONSCIENCE

 4.  

LATENT-(6-12 yrs) School Age Period of suppression, no obvious development Help child achieve positive experiences so that he/she will become ready to face the conflicts of adolescence

5.

GENITAL- (12yrs) Adolescent Focused on sexuality Developing sexual maturity; learning how to establish a satisfactory relationship with opposite sex Give opportunity to relate with opposite sex

  

PSYCHOSOCIAL THEORY

• • • •

Erik Erikson- trained in psychoanalysis theory Focuses on psychosocial tasks that are accomplished throughout the life cycle Stresses the importance of culture and society to the development of one’s personality Unsuccessful resolution of psychosocial crisis leaves the individual emotionally handicapped 4 aoih0718

Pedia 8 STAGES 1. Trust vs Mistrust (0-18 mos) *Feeding  Foundation of all psychosocial tasks  Psychosocial Theme: “To give is to receive”  Developed by:  Satisfying needs at all times: feed upon demand (because stomach capacity is low and baby easily gets hungry  Parental caring must be consistent and adequate  Giving an experience that will add to security (e.g. touch, hugs and kisses, eye-to-eye contact, soft music) 2.  

Autonomy vs Shame and Doubt (18 mos- 3 yrs) Toddler *Toilet Training If everything is planned or done for the child, autonomy is not developed Developed by:  Giving opportunity for decision-making, offering choices, rather than judge  Setting limits is the parents’ moral obligation

3.   

Initiative vs Guilt (3-6 yrs) Preschool *Doing basic things Guilt: anger turned inward See play as work and take it seriously, if failed the child cry so much Developed by:  Giving opportunity to explore new places and events  Provide activities that can enhance imagination, creativity and fine motor skills e.g. modeling clay, finger painting  If child fails in a play, don’t say “It’s just a game”, instead encourage child to accept defeat and to do his/her best next time

4.  

Industry vs Inferiority (6-12 yrs) School age *School Learns how to do things well Developed by:  Giving opportunity on short assignments and projects

5.  

Identity vs Role Confusion (12-20 yrs) Adolescent *Peers Learns who he/she is, what kind of person will he/she become by adjusting to new body image Emancipation from parents: liberation/freedom

6. Intimacy vs Isolation (20-25 yrs) Young Adult *Love  Looking for lifetime partners, career-focused 7. Generativity vs Stagnation (25-45 up to 60-65 yrs) Middle Adult *Parenting 8. Ego Integrity vs Despair (65 yrs) Late Adult *Reflection COGNITIVE THEORY

• • •

Jean Piaget- Swiss Psychologist Defines cognitive acts as ways in which the mind organizes & adapts to its environment SCHEMA- individual’s framework of thought

STAGES OF COGNITIVE DEVELOPMENT A.

Sensorimotor (0-2 yrs): “Practical Intelligence”, words and symbols not yet available

SCHEMA Neonatal Reflex/ Stimulus Response Primary Circular Reaction

AGE 1 mo

Secondary Circular Reaction

4-8 mos

Coordination of Secondary

8-12 mos

1-4 mos

BEHAVIOR All reflexes Activities r/t body, discover persons, no object permanence, repetition of behavior Activities not r/t body, object permanence, memory traces present, anticipate familiar events Exhibit goal-directed activities, sense of permanence 5 aoih0718

Pedia Circular Reaction Tertiary Circular Reaction Invention of new means thru mental combination

12-18 mos 18-24 mos

Preoperational Thought (2-7 yrs) SCHEMA AGE Pre-conceptual 2-4 yrs

Use trial and error in discovering places and events, space and time perception Invent new means by active experimentation, Transitional phase to Preoperational thought period

B.

Intuitive

4-7 yrs

BEHAVIOR Thinking basically complete, literal and static Concept of time: NOW Concept of distance: what can be seen ANIMISM- inanimate object has life SYMBOLIC PLAY Irreversibility of thinking Beginning of causation Egocentric in play, thought and behavior Unidimensional classification (texture, color, length one at a time)

C. Concrete Operational Thought (7-12 yrs) BEHAVIOR • Find solution to everyday problems with systematic reasoning • Concept of REVERSIBILITY • Concept of CONSERVATION • Cooperative Interaction- relates own point of view with others • Activity: Collecting • Multidimensional classification

D.

Formal Operational Thought (12 yrs) BEHAVIOR • Cognition achieved its final form • Solve hypothetical problems with scientific reasoning • ABSTRACT THINKING and mature thought • Concept of time: past, present and future • Activity: Talk time- sort out opinions and current events THEORY OF MORAL DEVELOPMENT • Lawrence Kohlberg (1984) – recognized the theory of moral development as considered to closely approximate cognitive stages of development • Not all persons may reach all stages; may be fixated in one stage STAGES OF MORAL DEVELOPMENT AGE (YEAR) 0-2 Infant 2-3 Toddler

STAGE Premoral/Amoral or Prereligious Pre-conventional (Level I) 1

4-7 Pre-schooler

Pre-conventional (Level I) 2

7-10 School age

Conventional (Level II) 3

10-12 School age

Conventional (Level II) 4

DESCRIPTION Not concerned with what is right or wrong Punishment/ obedience orientation (heteronomous morality). Child does right because parents tell him/her to and to avoid punishment Individualism. Instrumental purpose and exchange. Carries out action to satisfy own needs and rather than society. Will do something for another if that person do something for the child (“Do for me and I do for you”) Orientation to interpersonal relations of mutuality. Child follows rules because of a need to be a “good” person in own eyes and the eyes of others (“Good boy, Nice girl social concept”) Maintenance of social order, fixed rules and authority. Child finds following rules satisfying. Follows rules of authority figures as well as parents in an effort to keep the “system” working (“Law and Order Orientation”) 6 aoih0718

Pedia 12 Adoles-cent

Post Conventional (Level III) 5

12 Adolescent

6

Social contract, utilitarian law- making perspectives. Follows standards of society for the GOOD OF ALL people Universal ethical principle orientation. Follows INTERNALIZED STANDARDS of conduct

DEVELOPMENTAL MILESTONES INFANCY • PLAY: Solitary, non-interactive (begins at 4 mos) • BEST TOYS: mobiles, teethers, music box, rattles • FEAR: Stranger anxiety – Begins at 6-7 mos – Peaks at 8 mos – Fades at 9 mos NEONATE • Largely reflexes • Complete head lag • Hands fisted • Cries without tears • Visual fixation for human face 1 MONTH • Dance reflex disappears • Looks at mobiles – Prefers checker boards with angles and not pastel colors with contours – Hang at least 8 in. (20 cm) from head 2 MONTHS • Holds head up when in prone • (+) Head lag when pulled to sitting position • (+) Social smile • Cries with tears • Closure of posterior fontanel (2-3 mos) 3 MONTHS • Holds head and chest up when in prone • Follows object past midline • Palmar grasp and tonic neck reflexes are fading • (+) Hand regard • Coos, Bubbles 4 MONTHS • Turns from stomach to back, needs space to turn • Complete head control when pulled to sitting position • Solitary play begins • Laughs aloud • Recognizes mother 5 MONTHS • Assumes crawling stance • Places objects in mouth (give teething rings) • Handles rattle well • Moro reflex disappears (4-5 mo) • Reaches out to be held • Cries when toy is removed 6 MONTHS • Rolls from back to stomach • Sits with support 7 aoih0718

Pedia • • •

Starts to move from crawling stance Handles bottle well Says vowel sounds “ah”

•

Eruption of 1st temporary teeth then every mo. Thereafter (1st 2 lower central incisors) • Exhibits stranger anxiety 7 MONTHS • Rocks from crawling stance • Transfers object from hand to hand • Likes object that is good in size • Bites aggressively • Resists unwanted food/object • Cries when mother leaves 8 MONTHS • Sits without support • Uses pincer grasp • Peak of stranger anxiety • Responds to often used words • Plantar grasp (8-9 mos) and Babinski reflexes disappear 9 MONTHS • Creeps and crawls extensively • (+) Neat pincer grasp • Combines 2 syllables (Mama, Dada, Yaya) 10 MONTHS • Pulls self to stand, holding on to furniture • Understands the word “no” and simple commands; aware of approval and disapproval • Responds to own name • Plays peak-a-boo, pat-a-cake 11 MONTHS • Stands with assistance • Recognizes objects by name • Has a favorite toy • Explores environment • Has 3-word vocabulary 12 MONTHS • Stands alone

• • • • • •

Takes 1st step Walks with assistance Pulls toy Drinks from a cup Cooperates in dressing Likes nursery rhymes

CONCERNS: INFANTS • COLIC – Paroxysmal abdominal pain, common among < 3 mos. – S/Sx: Loud crying, flushed face, fists clenched, tensed abdomen – Causes: • Overfeeding • Swallowing of too much air • Milk formula very high in CHO • Tensed mother during breast feeding – Management: • Burp baby in the middle and after breast feeding or every 1 oz. of milk formula 8 aoih0718

Pedia •

•

•

•

Keep baby in upright position on mother’s chest or shoulder or in R side lying position on mother’s arm/lap CONSTIPATION/DIARRHEA – Causes: • Inaccurate mixing of formula • Adding too much sugar • Not diluting milk properly • Using condensed milk • Introduction of solid foods with too much fruits/sweets WEANING- during 6 months – Criteria • Child is able to approximate lips to the cup

• Child begins to experience ↓ sucking intensity – Choose a good day/mood for best cooperation – Don’t rush it – Don’t set time table – Provide reassurance that giving up breast/bottle doesn’t mean end of physical contact with mother NIGHT BOTTLE SYNDROME – Bedtime bottle is hardest to give up – Danger of propped bottle • Tooth decay • Aspiration, may lead to pneumonia

TODDLER • PLAY: Parallel (2 toddlers playing separately); provide 2 similar toys • BEST TOYS: waddling duck, pull-push trucks, tricycle, building blocks, pourding peg, erector set • FEAR: Separation anxiety • Begins at 9 mos • Peaks at 18 mos • PHASES: Separation anxiety 1. Protest: crying, screaming, searching for a parent, rejects stranger 2. Despair: withdrawn, depressed, uninterested 3. Denial/Detachment: uncommon, occurs only after lengthy separation • Copes by forming shallow relationship with others, being self-centered & attaching primary importance to material objects • Detaches from parents to escape the emotional pain of desiring parent’s presence • A form of resignation, not of contentment 15 MONTHS (Plateau Stage) • Walks alone • Creeps upstairs • Cannot throw ball without falling • Stacks 2 blocks • Puts small pellets into narrow necked bottle • Holds spoon well, rotates spoon, uses cup well • Scribbles voluntarily with pencil • Uses 4-6 words 18 MONTHS • Walks well, runs clumsily and falls, jumps in place, seats self on a chair • Walks up and downstairs holding on to a person’s hand or railing • Throws ball overhead without falling • Builds 3-4 blocks • No longer rotates spoon • Height of possessiveness “MINE” • Temper tantrums more evident 9 aoih0718

Pedia • Uses 7-20 words • Names one body part • BOWEL CONTROL achieved 24 MONTHS (Terrible Two’s) • Walks up and downstairs alone with 2 feet on one step before advancing • Runs fairly well with wide stance • Picks up objects without falling • Kicks ball forward • Opens doorknobs, unscrews lids • Builds 6-7 blocks • Uses 50-200 words (2-word sentences) • Pulls people to show them something • DAYTIME BLADDER CONTROL achieved 30 MONTHS • Jumps down from a chair • Stands on one foot momentarily • Makes simple lines, strokes or crosses with pencil, can copy a circle • With good hand-finger coordination • Knows full name, holds up fingers to show age • Temporary teeth complete (20 deciduous teeth, last to appear: posterior molars) 36 MONTHS • Rides a tricycle • Walks up and downstairs using alternate footing • Broad jumps • Buttons and unbuttons shirt • Draws a cross • Builds a tower of 9-10 blocks, builds a bridge with 3 blocks • Knows full name and sex • Speaks fluently (300-900 word vocabulary) • Learns how to share • NIGHTTIME BLADDER CONTROL achieved CHARACTER TRAITS: TOODLER • Scaphoid abdomen- underdeveloped muscles • Negativistic: “No!”- a way to search for autonomy/ independence – Limit questions, offer options TEMPER TANTRUMS – Reasons: • Inadequate vocabulary to express feelings in a socially-acceptable manner • Response to unrealistic requests of parents • Response to difficulty in making choices/decisions – Ignore the behavior • Rigid, stereotype

•

•

RITUALISTIC/DAWDLING- wasting a lot of time accomplishing a task – Reasons: • Asked to do something that is too difficult for them • Short attention span to remain interested in the task – Give ample amount of time for mastery TOOTH BRUSHING – 2-2½ yrs: start of tooth brushing – 3 yrs: tooth brushing with little assistance – 6 yrs: tooth brushing alone 10 aoih0718

Pedia •

– Right time to bring the child to the dentist: when temporary teeth are complete (at 30 mos) TOILET TRAINING – 3 Clues: • Can stand, squat and walk alone • Can communicate toilet needs • Can maintain dryness for an interval of 2 hrs

PRESCHOOL • Idea about death: a form of sleep, reversible • Beginning development of conscience thru punishment and reward • PLAY: Associative/ Cooperative • BEST TOYS: play house, modeling clay, finger paints, dolls, cars, doctor’s set • FEARS: Body Mutilation/ Castration fear, dark places, witches, ghosts, thunder and lightning 4 YEARS (Furious Four’s) • Catches ball reliably, throws ball overhead, jumps/skips on 1 foot • Laces shoes but can’t tie a bow • Copies a square • Draws 3 body parts to stick figure • Uses scissors to cut pictures • Knows 4 basic color • Uses 1,500 words but frequently does not know meaning • Cannot keep secrets • Quarrelsome, selfish, impatient, boasts, with mood swings 5 YEARS (Frustrating Five’s) • Skips/hops on alternate feet • Throws and catches ball • Jumps rope • Can walk backwards with heel to toe • Can tie shoe laces with bow • Copies triangle • Draws 7-9 parts of a man

• • • •

Prints few letters, numbers and words such as 1st name Has imaginary playmate Uses 2,100 words, asks meaning of words Can keep secrets

CHARACTER TRAITS: PRESCHOOL • Curious (“WHY?”), creative, imaginative, imitative – Parents must live by example not to cause confusion to the child • IDENTIFICATION to parent of same sex, attachment to parent with opposite sex

– – –

Oedipal Complex: little boy loves mommy, imitates daddy Elektra Complex: little girl loves daddy, imitates mommy Preschoolers need parental figure for the formation of identification

BEHAVIOR PROBLEMS • Telling tall tales: brought by over imagination • Imaginary playmate: way to release tension and anxiety • Magical Thinking: transductive reasoning (fat means pregnant) • Sibling rivalry: esp. among 4 yrs, jealousy to a newly delivered baby • Preschooler regresses: bed wetting, thumb sucking, baby talk • Masturbation: sign of boredom; divert attention by offering a toy SCHOOL AGE 11 aoih0718

Pedia • •

• • • •

PLAY: Competitive FEAR: School Phobia – Causes: • Separation anxiety • Overprotective parent and overdependent child • Strict teacher • New activities in school – Resolve underlying cause – Spend time with the child, orient child to the new environment – Make child secure OTHER FEARS: Displacement from school, loss of privacy, death Idea about death: (7-9 yrs) permanent loss of corporal life SIGNIFICANT OTHERS: teacher and peers of same sex SIGNIFICANT DEVELOPMENT – prone to greenstick fractures – have a mature vision

6 YEARS • Boys and girls are of same height • Year of constant motion/ Clumsy movements • Can ride a bicycle

• • • • • •

Temporary teeth begins to fall, permanent teeth begins to appear (1st molars) Defines words by their use Recognizes all shapes Begins to interact with God Teacher: authority figure Nail biting common

7 YEARS (Eraser Year) • Age of assimilation (ability to incorporate new ideas, objects and experiences into one’s framework of thought) • Quitting down period • Can tell time • Copies a diamond • Enjoys teasing and playing alone • Differences in sex seen in play • Strives for perfection 8 YEARS (Best friend Stage) • Expansive age • Smoother/graceful movements • Understands past, present and future • Can count backwards • Loves to collect objects • With same sex best friend • Whispering and giggling common 9 YEARS (Gang Age) • Coordination improves • Takes care of body needs completely, assumes responsibility for own health • Tells time correctly • Hero worship common • Has secret code • Belongs to all boys or all girls group of friends • Teacher finds this group difficult to handle • Cheating, lying and stealing are common 12 aoih0718

Pedia 10 YEARS (Collecting Age) • Age of Special Talents • Ready for competitive games • Writes legibly • Joins organizations • Well-mannered with adults but critical of them (part of identity formation) • Likes to perfect things 11-12 YEARS (Preadolescent) • Full of energy and constantly active • Share secrets with friends, Secret language are common • Sociable and cooperative GROWTH SPURT • Girls: 10-12 yrs • Boys: 12-14 yrs CHARACTER TRAITS: SCHOOL AGE • Industrious • Loves to collect objects • Sees self in the eyes of the teacher and classmates • Compares abilities and achievements with peers PEER GROUPS teaches: • To see oneself thru the eyes of others • How to be a leader and a follower • When to be assertive and to yield • Group loyalty • Conformity to group standards • How to be a good sport • How to accept and carry out responsibilities • Cooperation • Independence from adults BEHAVIOR PROBLEMS • Can’t bear to lose they will cheat, lie and steal • Reasons for cheating – Imitating adults – Depends on practicality of the situation • Reasons for lying – Confusion in child’s cognitive abilities and egocentrism – Inability to separate make believe/fantasy from reality – Failure to come up with expectations • Reasons for stealing – Confusion over perceived ownership – Impulse of peer pressure – “Getting back” on embarrassing parents CONCERNS: SCHOOL AGE • Safety – Motor vehicular accidents – Drowning – Open flame burns • Nutrition – Fondness for junk foods – Skipping meals/ eating in school – Obesity • Teach nutrient value of food 13 aoih0718

Pedia • • •

•

Control of sale of junk foods Packed snacks/lunch Prevention of obesity • Weight reduction program • Close weight monitoring Sex Education on: – Menstruation and reproductive organ function – Secondary sex characteristics development – Moral and social implication of sexual maturity

SIGNS OF SEXUAL MATURITY GIRLS Increase in size of breasts (Thelarche-1st sign) and genitalia (until 18 yrs) Widening of hips Appearance of axillary and pubic hair Menarche-last sign

BOYS Appearance of axillary and pubic hair (Adrenarche) Deepening of voice Development of muscles Increase in size of testes and penis- 1st sign (until 17 yrs) Production of viable sperm- last sign (nocturnal emission by 17 yrs)

ADOLESCENT • Age of transition from childhood to adulthood • FEARS: obesity, acne, death, homosexuality, replacement from friends • SIGNIFICANT OTHERS: peers of opposite sex • SIGNIFICANT DEVELOPMENT: • Conflict between own needs of sexual satisfaction and societal expectations • Core concern: change of image and acceptance of opposite sex • Distinct odor: due to stimulation of Apocrine glands • PERSONALITY TRAITS • Idealistic, rebellious, reformers, conscious with body image CONCERNS • Motor vehicular accidents • Masturbation: causes conflict with morality • Peer Pressure: smoking, alcoholism, drug addiction, premarital sex • Body image: eating disorders affecting nutritional state • Anorexia nervosa • Bulimia (Binge-eating) PART 2. IMMEDIATE CARE FOR THE NEWBORN 8 PRIORITIES OF THE NEWBORN IN THE FIRST DAYS OF LIFE 1. Initiation and maintenance of respiration 2. Establishment of extrauterine circulation 3. Control of body temperature 4. Intake of adequate nourishment 5. Establishment of waste elimination 6. Prevention of infection 7. Establishment of infant-parent relationship 8. Developmental care that balances rest and stimulation for mental development INITIATION AND MAINTENANCE OF RESPIRATION Nursing Alerts:  Lung function begins only after birth  Initiation of airway is crucial adjustment among newborns  Most neonatal deaths within 24-48h is caused by inability to initiate airway How: Remove secretions 14 aoih0718

Pedia Proper suctioning with a catheter  Place baby’s head to the side  Suction mouth first before nose to prevent aspiration (NB are nasal obligate)  Suction for 5-10 sec  Suction gently and quick  Prolonged deep suctioning may lead to:  HYPOXIA  LARYNGOSPASM  BRADYCARDIA

 

Evaluate for airway patency: Cover one nostril at a time If not suctioning is not effective, effective laryngoscopy is required to open the airway. After deep suctioning, an endotracheal tube can be inserted and oxygen can be administered by a positive pressure bag and mask with 100% oxygen at 40-60b/min.

Alerts (with O2 use):  No smoking  Must be humidified (not to dry mucosa)

 

Cover mouth and nose not the EYES→corneal dryness Avoid O2 overdosage, it can cause:

  

Retinal scarring: Retrolental 15phthalmic15s or Retinopathy of Prematurity (ROP) Bronchopulmonary Dysplasia (BPD)- obstructive pulm. Disorder

If meconium stained, never give O2 with pressure bag → atelectasis

ESTABLISHMENT OF EXTRAUTERINE CIRCULATION

FETO-P  FETO-PLACENTAL CIRCULATION Placenta→ Umbilical vein (O2 blood)→ liver→ Ductus venosus→ IVC→ RA ( pressure, 70% blood)→ Foramen Ovale→ LA→ mitral valve→ LV→ Aorta→LE Remaining 30% blood→ tricuspid valve → RV → PA → lungs (non-functioning, for nourishment)→ lung vasoconstriction → Ductus arteriosus → Aorta → UE LE & UE (unO2 blood) → placenta (for oxygenation via simple diffusion) 

SYSTEMIC CIRCULATION 15 aoih0718

Pedia – –

Initiated by lung expansion/ pulmonary ventilation Completed by cutting of the cord PCO2, ↓Po2 (initiates 1st breath of the NB) ↓ ↓ PA pressure (sustains breathing) Po2

↓ placental blood flow

LA & LV

(DA closure) (closure of DV & AVA)

pressure (FO closure)

 6.

2 Ways to facilitate closure of Foramen Ovale Tangential Footslap • Never stimulate baby to cry unless secretions are fully drained • Characteristic of cry: – Strong, vigorous, lusty- Normal – Cat-like “Meow”- Criduchat Syndrome – High-pitched, shrill- Hypoglycemia/ ICP

7.

Proper Positioning: R side-lying to L side pressure of the heart



Structure Foramen Ovale Ductus Arteriosus

Approp. Time of Obliteration (begins to close within 24h) 1yr (begins to close within 24h) 1 mo

Ductus Venosus Umbilical arteries

2 mos 2-3 mos

Umbilical vein

2-3 mos

Structure Remaining Fossa Ovalis (otherwise: ASD) Ligamentum arteriosum (otherwise: PDA) Ligamentum venosum Lateral umbilical ligament Interior iliac artery Ligamentum teres hepatis

Best position immediately after birth • NSD: Trendelenburg • CS: supine/crib level



Signs of ICP (initial) abN large head (>35 cm) Bulged/tensed fontanel (Crack spot- Macewen Sign) Projectile vomiting- surest sign of cerebral irritation HTN with widened pulse pressure, ↓ HR, ↓RR (Cushing’s triad) Diplopia (for older children) High-pitched, shrill cry (late sign) TEMPERATURE REGULATION

 

Goal: to maintain T not <36.5 °C or 97.7 °F Factors leading to Hypothermia – Prematurity: poikilothermic (cold blooded)- easily adapt to T of envt due to immature thermoregulating system (Hypothalamus) – Thin skin and ↓ SQ fats – Inability to shiver – Born wet

 Process of Heat Loss 1. Evaporation- from body to air 2. Conduction- from body to cold, solid object 3. Convection- from body to cooler, surrounding air 4. Radiation- from body to a cold, solid object not in contact with the body 

Effects of Hypothermia (Cold Stress) – Earliest sign: HR 1. Hypoglycemia- due to glucose utilization→ ↓ glucose to the brain → CP (irreversible brain damage) 16 aoih0718

Pedia 2. Metabolic acidosis- due to catabolism of brown fat or brown adipose tissue (best insulator of NB, found at neck, kidneys and adrenals) → formation of lactic acid and ketone bodies 3. Kernicterus- due to build-up of bilirubin in the brain 4. Additional fatigue to already stressed heart  Prevention of Cold Stress 1. Dry and wrap NB with a blanket (prevent evaporation) 2. Keep NB away from cold objects and outside walls (prevent radiation) 3. Shield NB from drafts (prevent convection) 4. Perform all treatments on a warm, padded surface (prevent conduction) 5. Mechanical measures - radiant warmer - isolette/incubator *should be prewarmed first before placing the NB 6. Prevent unnecessary body exposure 7. Cover body areas not being examined 8. Embrace/ Skin-to-skin contact (KMC) ESTABLISHMENT OF ADEQUATE NUTRITIONAL INTAKE  Physiology of Breast milk Production ↓Estrogen, ↓Progesterone→ Anterior Pituitary Gland→ Prolactin→ Acts on acinar cells (alveoli) → Produces Foremilk→ Stored in lactiferous (collecting) tubules Baby sucking on breasts→ Posterior Pituitary Gland→ Oxytocin→ Contraction of lactiferous tubules→ Milk Ejection (Let down) Reflex 

    

 



Advantages of Breast feeding – Very economical – Always available at right T – Helps in rapid involution due to Oxytocin production • Breast- 4 wks • Uterus- 6 wks – ↓ breast CA incidence – Baby has more IQ than bottlefed – Contains Antibodies: IgA – With Lactobacillus bifidus (protects GIT from pathogens) – With lysozyme (destroys bacterial cell membrane) – With macrophage • Store in sterile plastic container for macrophage not to stick to the bottom – If stored in freezer: good for 6 mos; don’t reheat (even in microwave oven for milk formula): will destroy contents Newborns are able to digest simple CHO unable to digest fats due to lack of lipase CHON can be broken down partially (to serve as Ag & provoke an allergic reaction) NB has small stomach capacity (90 ml) with rapid intestinal peristalsis (bowel emptying time: 2.5-3 hrs) Initiation of Breast feeding – NSD: asap – CS: after 4 hrs Breastfeeding can begin ASAP after birth Bottle-fed NB may be offered a few ml of sterile water or D5water 1-4 hrs after birth before feeding with formula Disadvantages of Breast feeding – No iron: prone to develop anemia if fully breastfed – Possibility of CMV, HIV and Hepa B virus transfer – Father cannot bond as well

STAGES OF BREAST MILK Stage Colostrum Present 2-4 days

CHO ↓

CHON

17 aoih0718

Fat ↓

Others Ig Minerals Vit ADEK

Pedia Transitional Present 4-14 days Mature Present 14 days BREAST MILK VS. COW’S MILK Milk CHO Mature Breast Lactose easily milk digested, (-) constipation, sour milk smell of stool Cow’s milk ↓

-

-

↓

CHON ↓ Lactalbumin

Casein with curd: hard to digest, (+) constipation

Minerals Water soluble Vit -

Fat Linoleic acid for brain dev’t and skin integrity

Others -

Phosphorus Minerals: traumatic to kidneys: force fluids

HEALTH TEACHING OF BREAST FEEDING Proper hygiene • Hand washing • Cleanse caked 18phthalmic on nipples with cotton soaked in lukewarm water from inner to outer motion Proper positioning • Upright, sitting • Mother should be relaxed, avoid tension not to interrupt flow of milk, otherwise baby will develop colic Stimulate and evaluate feeding reflexes • ROOTING: touch side of lips, mouth will open • purpose- to look for food • if not stimulated: disappears in 6 wks • N: disappears after 3-4 mos. To 1 yr • SUCKING: touch middle of lips • if not stimulated: disappears in 6 mos; offer pacifier if on prolonged NPO • SWALLOWING: when food touches posterior portion of tongue • EXTRUSION/ PROTRUSION: when food touches anterior portion of tongue • purpose- to prevent poisoning • disappears at 4 mos (baby can spit up) Criteria of effective sucking • Baby’s mouth is well hiked-up to areola, sucking is quiet and has no sound produced • Mother experiences after pain • Other nipple is flowing with milk To prevent cracked nipples and initiate proper production of oxytocin • Begin by 2-3 min. per breast • by 1 min. per day until 10min. per breast or 20 min. per feeding For proper emptying and continuous milk production per feeding • Feed baby on last breast you fed PROBLEMS EXPERIENCED IN BREAST FEEDING 





Engorgement  Feeling of tension/fullness  Management:  warm compress if breast feeding  cold compress or supportive bra if bottle feeding Sore Nipple  Cracked, wet painful nipple  Management:  Exposure of affected breast to air or to 20-watt bulb 12-18 in. away from breast  Avoid using plastic liner bra Mastitis  Breast inflammation due to Staphylococcus aureus 18 aoih0718

Pedia 



Causes:  Improper breast emptying  Unhealthy sexual practices  Improper hygiene Management:  Manually express infected breast but don’t feed this milk to the baby  Take antibiotics as ordered and continue breast feeding

CONTRAINDICATIONS IN BREAST FEEDING  Maternal Conditions  Human Immunodeficiency Virus (HIV)  Cytomegalovirus (CMV)  Hepatitis B virus (HBV)  taking Warfarin (Coumadin)  Newborn Condition  ABO/Rh incompatibility: Erythroblastosis fetalis, Hydrops fetalis,  Inborn errors of metabolism: PKU, Galactosemia, Tay Sach’s disease ESTABLISHMENT OF WASTE ELIMINATION 

Different Stools – Meconium (Physiologic Stool) • Blackish, greenish, sticky, tar-like, odorless (due to sterile intestines) • Contents: amniotic fluid, shedding of intestinal mucosa and secretions/mucus, vernix, hormones • N: passed within 24-36 hrs, otherwise with GI obstruction:  Hirschsprung’s disease  Imperforate anus  Meconium ileus (Cystic fibrosis) – Transitional Stool • On 2nd to 10th day in response to feeding pattern • Greenish, loose, slimy, like diarrhea to untrained eye (esp. primi mothers) – Breastfed Stool • Golden yellow, soft, mushy with sour milk smell ( lactic acid) – –

• Frequently passed: 3-4X/day Bottle-fed Stool • Pale yellow, formed, hard with typical offensive odor • Seldom passed: 2-3X/day With supplementary foods added • Brown, odorous

INDICATION OF STOOL CHANGES  Jaundice: light stool  Undergoing phototherapy: bright green  Milk allergy: with mucus  Bile duct obstruction: clay  s/p Barium enema: chalk-clay  Upper GI bleeding: black (melena)  Lower GI bleeding (Anal fissure): blood flecked (hematochezia)  Intussusception: currant jelly  Hirschsprung’s disease: ribbon-like  Malabsorption syndrome (Celiac disease, Cystic fibrosis): steatorrhea- fatty bulky, foul smelling PART 3. ASSESSMENT FOR WELL-BEING APGAR SCORE  Special Considerations – 1st 1 min: general condition of the baby

–

1st 5 min: capability to adjust to extrauterine life (MOST IMPORTANT) 19 aoih0718

Pedia

–

1st 15 min: (optional) A-ppearance: Color P-ulse Rate: HR (most impt) G-rimace: Reflex irritability A-ctivity: Muscle tone R-espiratory effort  NB is expected to cry after delivery within 30 sec, otherwise consider Asphyxia Neonatorum due to effect of Demerol or Morphine (give Naloxone/ Narcan 0.1 mg/kg) APGAR SCORING CHART CRITERIA Heart Rate Respiratory Effort Muscle tone Reflex irritability A. Catheter B. Tangential Footslap Color 

0 (-) (-) Flaccid NR

1 <100 Slow, irregular weak cry Some flexion Grimace

2 >100 Good, strong cry Well-flexed Cough/ Sneeze

NR Blue/ Pale

Grimace Acrocyanosis

Cry Pink all over

Interpretation of Score – 0-3: severely depressed, needs CPR, NICU admission – 4-7: moderately depressed, needs additional suctioning and O2 – 8-10: good health

PEDIATRIC CPR/ACLS

 

Mostly rooted from respiratory failure→ hypoxia if >5 min→ irreversible brain damage→ brain death A-irway (Open and Clear Airway)

 

Shake→ NR→ call for help Head-tilt-chin-lift (Sniffing position) or Jaw thrust if with head/neck (cervical) injury is suspected



B-reathing (Ventilating the lungs)  Check for breathlessness (Look, listen, feel)  Give 2 rescue breaths  Mouth-to-mouth  One-way mask with positive pressure ventilation  Infant: cover mouth and nose  >1 yr: cover mouth and pinch nose  If no chest rise, reposition the head or consider foreign airway obstruction  Remove it using:  Heimlich maneuver (Abdominal thrust) for child  Back blows and chest thrust for infant  Give O2 via face mask at highest 02 possible (10-15 LPM)  If still ineffective, intubate the pt  Endotracheal tube (ET)  Emergency tracheostomy (if with upper airway obstruction)

 

C-irculation (Cardiac Compression) Check for pulselessness  Infant: brachial/femoral  >1yr: carotid  Compression area: lower half of sternum; 1 finger breadth below the level of nipple line; 2 finger breadths above xiphoid process  Avoid compressing the xiphoid process: may injure liver, stomach and spleen

Cardiac Compression

Neonate < 1mo

Pulse check

Brachial/ femoral Chest encirclement- thumbs placed side by side ½-¾

Technique Depth (inch)

20 aoih0718

Infant 1mo- 1yr Brachial/ femoral

1-8 yrs

2-3 fingers

Heel of 1 hand

½-1

1- 1½

Carotid

Pedia Rate/min. Compression Ventilation ratio



>120 3:1 X 40 cycles

>100 5:1 X 20 cycles

100 5:1 X 20 cycles

C-irculation – Obtain IV access: • NB: umbilical vein • Peripheral (3 attempts within 90 sec) • <6 yrs: intraosseous (anterior tibia) • Central line (femoral, subclavian, jugular veins) – Give meds • Atropine: 0.02 mg/kg IV, IO, ET • Epinephrine (q 3-5 mins) – 1st dose: 0.01 mg/kg IV, IO – 0.1 mg/kg ET – 2nd dose: 0.1 mg/kg IV, IO, ET – Meds that can be given per ET • L-idocaine (1 mg/kg) for PVCs • E-pinephrine • A-tropine for bradycardia • N-aloxone (0.01mg/kg) – Should be flushed with 3-5 cc plain NSS then followed by several positive pressure breaths – Give 20cc/kg crystalloid solution (plain NSS or plain LR) as rapid IV bolus for 2-3 times until hypotension is corrected – If failed or in case of trauma with massive blood loss: give 10cc/kg colloid solution (Prbc), or 20cc/kg whole blood IV bolus, may give O negative blood immediately, don’t wait for crossmatching result.

Assess and Support: Temp (warmand dry) Airway (position and Breathing (stimulate t

RESPIRATION EVALUATION: SILVERMAN ANDERSON INDEX CRITERIA Chest movement (upper chest) Intercostal retractions (lower chest) Xiphoid retraction Nares dilatation Expiratory Grunt



Interpretation of Score

0 Synchronized

1 Lag on inspiration

See-saw

(-)

Just visible

Marked

(-) (-) (-)

Just visible Minimal Heard by stethoscope only

Marked Marked Heard by naked ear

21

aoih0718

2

Pedia – – –

0-3: normal, (-) RDS 4-6: moderate RDS 7-10: severe RDS

ASSESSMENT OF GESTATIONAL AGE: BALLARDS AND DOBUWITZ FINDINGS < 36 WKS 37-38 WKS Sole creases Anterior transverse Occasional creases in crease only 2/3 Breast nodule (dm) 2 mm 4 mm Scalp hair Fine and fuzzy Fine and fuzzy Earlobe Pliable (-) cartilage Some cartilage Testes and scrotum Testes in lower canal, Intermediate scrotum small, few rugae

>39 WKS Creases all over 7 mm Coarse and silky Stiff, thick cartilage Testes pendulous, scrotum full, extensive rugae

PRETERM BABIES  20-37 wks AOG  Abundant lanugo  Hypotonia (prone to respiratory problems)  Frog leg or lax position  Irregular RR with periods of apnea  Hypothermic  Poor suck and swallow reflexes  Thin extremities and skin  Male: Testes undescended  Female: Labia narrow  Classic Signs:  Scarf sign: elbow passes midline of the body  Heel to ear sign



Square window wrist: 90° angle

POSTTERM BABIES  >42 wks AOG  Classic Sign: Old man’s face  Wide and alert eyes  Long brittle fingernails  Skin desquamation  Profuse scalp hair  Long, thin body  Meconium staining (on nails and umbilical cord)  Hypoglycemic PART 4. NEONATE IN THE NURSERY SPECIAL AND IMMEDIATE INTERVENTIONS  Upon receiving – Proper identification (foot print)  Take anthropometric measurements Measurements Length Head Circumference Chest Circumference Abdominal Circumference 



Cm. 47.5-53.75 33-35 31-33 31-33

Ave. (Cm.) 50 34 32 32

In. 19-21.5 13-14 12-13 12-13

Bathing the baby  Initial: Oil bath  To cleanse and spread Vernix Caseosa (insulator and bacteriostatic)

 Full bath once the cord falls off and for baby of HIV (+) mother to ↓ transmission to the NB Dressing the umbilical cord  Small, thin cord= poor fetal growth 22 aoih0718

Pedia       

N: Check for 3 vessels: AVA Follow strict asepsis (to prevent Tetanus Neonatorum) Use triple dye, 70% alcohol or plain NSS Should be done with each diaper change or at least 2-3X/day Fold diaper below cord Leave 1 in. of the cord If IV infusion/BT is anticipated, leave about 8 in. of the cord: for umbilical vein cannulation (best access to NB; no nerve endings)





Check the cord q 15 mins for the 1st 6 hrs  Omphalagia: bleeding of the cord, suspect hemophilia  >30 cc: considered bleeding to a NB (because not yet capable of producing RBC)  Patent urachus: persistent moistening (fistula between bladder and umbilicus)  Nitrazine paper test: turned yellow: (+) urine Umbilical cord

 



Turns black: 3rd day Falls off: 7th-10th day, otherwise with Umbilical Granulation (without foul smell, not necessary with infection)  Mgt: Silver Nitrate and Cauterization

Crede’s Prophylaxis

 

Purpose: to prevent Opthalmia Neonatorum (Gonnorheal Conjunctivitis) from mother with untreated gonorrhea and Chlamydia trachomatis if delivered via NSD May be delayed until an hour or so after birth to facilitate eye contact & parent-infant bonding



Uses:

 





Erythromycin (0.5%) or Tetracycline (1%) 23phthalmic ointment (from inner to outer canthus) or drops Silver Nitrate 1% 2 gtts at lower conjunctival sac then washed with plain NSS after 1 min. to prevent staining (obsolete use because cannot protect against Chlamydial infection & can cause chemical conjunctivitis)

Administration of Vitamin K (Phytomenadione: Aquamephyton, Konakion, Cycomin)  To prevent hemorrhage r/t physiologic hypoprothrombinemia (because Vit K is not synthesized until intestinal bacteria are present)  Preterm: 0.5 mg IM; Term: 1.5 mg IM  Via Vastus lateralis or lateral anterior thigh (Rectus femoris) Weight taking  N: 3- 3.4 kg or 6.5- 7.5 lb  Arbitrary Lower Limit: 2.5 kg  Low Birth Weight: <2.5 kg or 5.5 lb

 

Small for Gestational Age: ≤ 10th percentile rank on the intrauterine growth curve



Large for gestational Age: ≥ 90th percentile rank, macrosomia > 4 kg Appropriate for Gestational Age: within the 2 standard deviation of the mean



Physiologic Weight Loss: 5-15% of birth weight during the 1st wk of life r/t voiding and limited intake

PART 5-A. PHYSICAL EXAMINATION AND DEVIATION FROM THE NORMAL IMPORTANT CONSIDERATIONS DURING PHYSICAL EXAMINATION • NB- cover areas not being examined • Infant- take RR first, move from least to most intrusive area • Toddler and Preschool- let them handle the instrument, allow to keep security blanket/favorite toy • School age and Adolescent- explain the procedure VITAL SIGNS TEMPERATURE • N: 36.5-37.5 °C • Take rectal temp. once to r/o imperforate anus • Insert about 1 inch of the thermometer, if pushed deeply→ peritonitis 23 aoih0718

Pedia IMPERFORATE ANUS • Congenital disorder, incomplete development or absence of anus in its position in the perineum • More common in M than F • 4 types 1. Atresia (anal or rectal) 2. Agenesis (anorectal)*no anal opening, most dangerous type 3. Stenos 4. Membranous* has anal opening •

Signs and Symptoms – Failure to pass meconium during 24-36 hrs (1st sign) – Abdominal distention – Vomitus of fecal material → aspiration pneumonia – (-) anorectal canal – (+) anal membrane – External fistula to perineum & GU system • Management – Temporary colostomy (colostomy care) – Anal surgical incision • Position post-op: sidelying or prone • Perform anal dilation as prescribed (use water soluble lubricant, insert dilator no more than 1-2cm deep) • Complication – Continence for a lifetime due to sacral anomalies and improper surgery HEART/CARDIAC RATE Normal values AGE AWAKE SLEEPING AVE. NB- 3mos 85-205 80-160 140 3 mos-2 yr 100-190 75-160 130 2 yr-10 yr 60-140 60-90 80 > 10 yr 60-100 50-90 75 • • •

NB 120-160 bpm, irregular Radial pulse: N: non-palpable, if palpated suspect Patent Ductus Arteriosus (PDA) Femoral pulse: N: palpable, if not suspect Coarctation of the Aorta (COA)

CONGESTIVE HEART FAILURE • Inability of the heart to pump sufficiently to meet the metabolic needs of the body • Due to Congenital Heart Diseases • Early Signs & Symptoms • HR at rest & slight exertion

• • • •

RR, distress Profuse scalp sweating (infants) Fatigue & irritability Sudden wt gain

CONGENITAL HEART DISEASE • Common in Girls • PDA, ASD • Common in Boys • TGA, TA, TOF, VSD • Causes • Familial • Exposure to Rubella (German Measles): dangerous during the 1st mo. (fetal heart is developing at 4-8 wks AOG) • Failure of the heart structure to progress • General Signs & Symptoms • CRY • Weak, muffled, loud, breathless • ACTIVITY LEVEL • Restless, lethargic • Unresponsive to pain 24 aoih0718

Pedia •

• • •

•

POSTURING • Hypotonia • Opisthotonus HR: persistent or ↓, (+) murmurs RR: , retractions with alar flaring, gasping, dyspnea with diaphoresis when supine, grunting with exertion such as crying or feeding FEEDING BEHAVIOR • Poor suck due to lack of energy and dyspnea • Difficult, uncoordinated suck, swallow and breathing • Slow, with pauses to rest • Poor weight gain

2 MAJOR TYPES • ACYANOTIC HD • L to R shunt • 50% enters the aorta, 50% reenters RV • CYANOTIC HD • R to L shunt • with venous admixture entering the systemic circulation

CARDIAC CATHETERIZATION • Fluoroscopy-guided insertion of radiopaque catheter inserted thru peripheral blood vessel (femoral or antecubital vein) via percutaneous puncture, combined with angiography (injection of contrast material/dye) thru the catheter into the circulation • Provides information about: • Oxygen saturation (saO2) of chambers and great vessels • Pressure changes • Cardiac Output (CO) and Stroke Volume (SV) • Anatomic abnormalities • Nursing Interventions: Pre-op – Measure accurate height/length and weight: essential to correct cath selection – Ask for hx of allergy to seafoods/iodine/dye – WOF S/Sx of infection at site to be used: severe diaper rash defers femoral approach – Check for presence and quality of both pedal pulses and mark them – Get baseline VS esp. saO2 – Give analgesic/sedative as ordered (Demerol/Midazolam/ Ketamine/Propofol) – NPO 6 hrs pre-op, with IVF to prevent hypoglycemia and dehydration as ordered • Nursing Interventions: Intra-op – WOF arrythmia during catheter insertion – WOF feeling of warmth, N/V, restlessness and headache, urticaria, flushing during injection of dye – Monitor VS: bradycardia, hypoTN may indicate hemorrhage or cardiac perforation • Nursing Interventions: Post-op – WOF hemorrhage • Maintain occlusive, water proof dressing at site • Check dressing for bleeding • Check site for hematoma • Ensure adequate fluid intake to prevent dehydration (due to blood loss, NPO status and diuretic action of the dye) and hypoglycemia – WOF thrombus formation • Check equality and presence of distal pulses • Check for T and color of affected extremity • If (+) venospasm: warm compress on contralateral extremity • Keep affected extremity straight to facilitate healing • Venous: 4-6 hrs • Arterial: 6-8 hrs • Give pain meds as ordered

25 aoih0718

Pedia

NORM •

Pulmonary Blood Flow – Ventricular Septal Defect (VSD) – Atrial Septal Defect (ASD) – Endocardial Cushion Defect (AV canal) – Patent Ductus Arteriosus (PDA)

VENTRICULAR SEPTAL DEFECT • Most common CHD • Abnormal opening between 2 ventricles (size: pinpoint to (-) septum) • Signs and Symptoms • Systolic murmur at lower sternal border and no other significant Sx, may have S/Sx of CHF depending on size of defect • ECG/CXR: RA, RV hypertrophy • Cardiac cath: saO2 at RA, RV • Management • Palliative: Pulmonary Artery (PA) Banding- to ↓ pulmonary blood flow • Corrective: Open Heart Surgery with cardiopulmonary (CP) bypass: VSD patch closure (using Dacron patch) ATRIAL SEPTAL DEFECT • Patent Foramen Ovale • Abnormal opening between 2 atria • Signs and Symptoms • Systolic murmur at upper sternal border and no other significant Sx; may have S/Sx of CHF before school age • ECG/CXR: RA, RV hypertrophy • Cardiac cath: saO2 at RA, RV • Management • Palliative: PA Banding- to ↓ pulmonary blood flow • Corrective: Open Heart Surgery with cardiopulmonary (CP) bypass: ASD patch closure (using Dacron patch) ENDOCARDIAL CUSHION DEFECTS • Or Atrioventricular (AV) canal – Associated with Down’s Syndrome 26 aoih0718

Pedia

•

•

– All chambers communicate – With low ASD and high VSD Signs and Symptoms – Moderate to severe CHF – Mild cyanosis when crying – (+) murmur – Cardiac cath confirms the dx Management – Palliative: PA Banding- to ↓ pulmonary blood flow – Corrective: Open Heart Surgery with cardiopulmonary (CP) bypass • Patch closure • AV valves reconstruction • Mitral valve replacement (with severe defect) • Cx post-op: CHF, mitral regurgitation, arrythmia, pulmonary HTN

PATENT DUCTUS ARTERIOSUS • Failure of DA to close • Signs and Symptoms – Continuous machinery-like murmur – Prominent, bounding radial pulse – ECG/CXR: RV hypertrophy due to pulm. vascular resistance and congestion – LV hypertrophy due to additional blood to PA that goes back to LA and LV • Management – Indomethacin (Indocin): Prostaglandin inhibitor that facilitates PDA closure in preterms and NB – Palliative: PA Banding – Corrective: PDA ligation: via L thoracotomy – Latest: Visual Assisted Thoracoscopic Surgery (VATS): uses thoracoscope and instruments placed on 3 small incisions on L chest (faster recovery) Obstructive Defects – Pulmonary Stenosis (PS) – Aortic Stenosis (AS) – Duplication of aortic arch – Coarctation of the Aorta (COA) PULMONARY STENOSIS • Narrowing of pulmonic valve • Extreme form: Pulmonary Atresia: no blood flow to the lungs, with hypoplastic RV • PDA compensates by shunting blood from aorta to PA • With ASD due to RA and RV pressure • Signs and Symptoms • Cyanosis (due to ↓ pulm. blood flow) • Typical murmur • Split S3 sound (in all CHF) • ECG: RV hypertrophy • Management • Balloon angioplasty (to dilate narrow valve) • Transventricular (closed) valvotomy or Brock Procedure (infant) • Pulmonary valvotomy with CP bypass (child) AORTIC STENOSIS • Narrowing of aortic valve • Only 50% of blood enters aorta • Signs and Symptoms • Feeding/exercise intolerance • Exercise intolerance, Active child may experience angina-like Sx: chest pain, dizziness, headache • Faint pulses, HR, ↓ BP, • Typical murmur, rough systolic sound and thrill • ECG/CXR: LV hypertrophy due to LV resistance and LA pressure → pulmonary HTN and edema

• •

Management Balloon Angioplasty: done in cath lab 27 aoih0718

Pedia

•

• Cx: Coronary artery insufficiency→MI → sudden death (1. Palliative) Aortic valvotomy then (2. Complete) valve replacement • Cx: bacterial endocarditis, ventricular dysfunction→ HF

DUPLICATION OF AORTIC ARCH • Causes pressure (compression) to trachea and esophagus • Signs and Symptoms – Dysphagia – Dyspnea – ECG/CXR: LV hypertrophy • Management – Closed heart surgery COARCTATION OF THE AORTA • Narrowing of aortic arch→ pressure proximal to the defect, ↓pressure distal to the defect • Signs and Symptoms • BP on upper extremities, ↓ BP on lower extremities (monitor 4-extremity BP) • Epistaxis, dizziness, headache, fainting • Weak or (-) femoral pulse, cold LE • Management • Percutaneous balloon angioplasty • Close Heart Surgery via thoracotomy incision • COA resection and end-to-end anastomosis of aorta • Enlargement of COA using a graft of prosthetic material or a portion of L subclavian artery • Cx: restenosis , ruptured aorta, aortic aneurysm or stroke Mixed Defects • Transposition of Great Arteries (TGA) • Total Anomalous Pulmonary Venous Return (TAPVR) • Truncus Arteriosus (TA) • Hyploplastic Left Heart Syndrome (HLHS) TRANSPOSITION OF GREAT ARTERIES • Aorta is arising from the RV and PA is arising from LV • No communication between systemic and pulmonary circulations, no oxygenation happens • Signs and Symptoms (in all cyanotic HD) • Cyanosis after 1st cry • Cardiomegaly and Polycythemia (in response to hypoxemia)→ thromboembolism→ CVA • CHF • Acceptable saO2≥75% • Management • Prostaglandin E1 to blood mixing temporarily

• • •

Palliative: Rashkind procedure or Balloon Atrial Septostomy (BAS) during cardiac cath. to blood mixing and to maintain CO over long period Complete: Intraatrial baffle repair to direct venous blood to mitral valve and pulmonary blood to tricuspid valve using prosthesis (Mustard procedure) or own atrial septum (Senning procedure) Complete: Arterial Switch Procedure with reimplantation of coronary arteries (done during 1st wks of life) • Cx: coronary insufficiency, arrythmia, ventricular dysfunction, HF

TOTAL ANOMALOUS PULMONARY VENOUS RETURN • Pulmonary veins enter RA or SVC instead of LA • With ASD (due to pressure in RA and RV) • Signs and Symptoms – RV hypertrophy, hypoplastic LV – Mild to moderate cyanosis – CHF (aspleenia) • Management – Complete: Open heart with CP bypass, includes • ASD patch closure 28 aoih0718

Pedia • •

Anastomosis of pulmonary veins to LA TAPVR Ligation • Cx: reobstruction, bleeding, dysrythmia- heart block, PA HTN, HF

TRUNCUS ARTERIOSUS • PA and aorta arise from 1 single vessel of a common trunk with VSD • Signs and Symptoms • CHF • Cyanosis and hypoxemia, murmur • Poor growth • Activity intolerance • Complications: brain abscess, bacterial endocarditis •

Management • Modified Rastelli procedure: VSD patch closure + excision of PA from aorta and attaching them to RV via homograft • Cx: HF, bleeding, PA HTN, arrythmia, residual VSD

HYPOPLASTIC LEFT HEART SYNDROME • Underdeveloped, non-functioning LV, with aortic atresia • With ASD and PDA to supply aorta with blood • Signs and Symptoms • Cyanosis until PDA closes→ progressive deterioration and ↓ CO→ CV collapse • Management • Inotropes IV, Prostaglandin E1 IV to keep PDA open • Norwood Procedure: PA anastomosis to create new aorta and creation of large VSD • Bidirectional Glenn shunt: pulmonary to systemic artery anastomosis to blood flow to the lungs • Modified Fontan Procedure • Connects RA and PA • An opening in the RA baffle is done to ↓ pressure • Separates oxygenated from unoxygenated blood but doesn’t restore N anatomy or hemodynamics • Heart transplant: best option • Problems: • Shortage of NB organ donor • Risk of rejection • Chronic immunosupression and infection ↓ Pulmonary Blood Flow • Tricuspid Atresia • Tetralogy of Fallot (TOF) TRICUSPID ATRESIA • Failure of tricuspid valve to open • With ASD and VSD, sometimes with PDA • Signs and Symptoms • Cyanosis, HR, RR, dyspnea at birth • Chronic hypoxemia with clubbing (older child) • Complications: • Bacterial endocarditis • Brain abscess • CVA • Management • Prostaglandin E1 IV at 0.1mg/kg/min to keep PDA open • Palliative: Balloon Atrial Septostomy (if with ↓ pulm. blood flow)

• • •

PA banding (if with pulm. blood flow) Bidirectional Glenn shunt Modified Fontan Procedure

TETRALOGY OF FALLOT • 4 Anomalies Present 29 aoih0718

Pedia

•

– P-ulmonic stenosis – V-SD (large) – O-verriding of aorta – R-V hypertrophy Signs and Symptoms – acute cyanosis at birth that progresses over 1 yr as PS worsens – murmur – Polycythemia→thromboembolism→ CVA

–

• •

Severe dyspnea relieved by squatting (older child) or knee-chest position (infant): ↓ venous return, lung expansion – Growth retardation – Clubbing of fingers and nails – Tet/Blue spells: acute episodes of cyanosis and hypoxia – Anoxic spells: when O2 demand> supply, usually during crying and after feeding – Syncope’ – MR – CXR: boot-shaped heart Complications: – Seizures, Brain abscess – CVA, or sudden death after anoxic spell Management – O2 and Morphine for hypoxic episodes – Propranolol (Inderal) to ↓ heart spasm – Palliative: Blalock Taussig Shunt (BTS) • pulm. blood flow and saO2 to the PA from L or R subclavian artery – Complete: Open heart (median sternotomy) with CP bypass, includes • Resection of infundibular stenosis (Brock Procedure) • VSD patch closure • Pericardial patch to enlarge RV outflow tract

MANAGEMENT: CHF/CHD • Monitor – VS, dysrythmias – I/O: weigh diaper – Weight OD (fluid retention) – Facial/peripheral edema – abN breath sounds • Maintain – Semi-Fowler’s, Knee-chest, squatting position – Neutral thermal environment – Bed rest, uninterrupted sleep – Adequate nutritional intake (small, frequent feeding; feed per demand) – Fluid restriction as ordered • Administer as ordered – Cool, humidified O2 – Sedatives – ACE inhibitors: Captopril (Capoten), Enalapril (Vasotec) – Digitalis (Lanoxin elixir): 50 mcg/ml with HR deferral – Diuretics (Furosemide) with BP deferral • WOF K+ levels (K+ ↓ drug effect, ↓K+ potentiates Digitalis toxicity: bradycardia and vomiting) – K+ supplements DIGITALIS PRECAUTIONS • Digitalis (Lanoxin elixir): 50 mcg/ml • N blood level= 0.8- 2 mcg/L • (+) inotropic ( contractility)

• • • •

(-) chronotropic (↓ HR): S/E (-) dromotropic (↓ AV conduction) Drug overdose: if infant receives more than 50 mcg/dose HR deferral: <90 infant; <110 young child; <70 older child 30 aoih0718

Pedia • • • • • • • •

Administer 1 hr a.c. or 2 hrs p.c. Don’t mix with milk, foods or drink If <4hrs has elapsed, administer the missed dose; otherwise give it on the next dose If child vomits, don’t give a 2nd dose Don’t double the dose for missed doses Give water or brush teeth after the meds Keep meds in locked cabinet Call poison control center immediately if accidental overdose occurs

HOME CARE AFTER CARDIAC SURGERY • AVOID – Playing outside for several wks – Activities that can cause falls (bike riding) for 2-4 wks – Crowds for 2 wks – Salty diet; introducing new food – Putting cream, lotion, powder on the incision until completely healed – Physical education for 2 months – Immunizations, invasive procedures & dental visits for 2 months • Advise parents – Discipline child normally – Importance of dental visit q6 mos. after age 3, informing dentist of cardiac problem – Call MD when coughing, RR, cyanosis, A/N/V, diarrhea, pain, fever, swelling, redness or drainage occurs at site of incision ACQUIRED HEART DISEASE • RHEUMATIC FEVER- inflammatory autoimmune disease following an infection caused by Group A β hemolytic Streptococcus (within 2-6 wks) • RHEUMATIC HEART DISEASE- if with cardiac valve damage • Self-limited • Affected body parts: • Joints • Skin • Brain • Serous surfaces • Blood vessels • Heart (muscles and valves)

31 aoih0718

Pedia RHD: MAJOR SIGNS AND SYMPTOMS • 1. POLYARTHRITIS – Multiple joint pain (for 1-2 days) – Reversible and migratory affecting large joints: knees, hips, elbows, shoulders, wrists, ankles – With acute T during 1st 2 wks persisting for 4 wks in untreated pt • 2. CARDITIS – Initial S/: HR out of proportion to T, even at rest/sleep – Involves all heart layers – (+) murmurs – CHF: cardiomegaly, pericardial friction rub (chest pain), pericardial effusion, mitral valve stenosis • 3. ERYTHEMA MARGINATUM – Distinct erythema macule with clear center and wavy demarcated border – Transitory,red skin lesions, non-pruritic rash, found in the trunk and proximal extremities • 4. SQ NODULES – Rare, small (0.5-1 cm), non-tender swellings that persists indefinitely after disease onset and gradually resolve without resulting damage – Found over joints • 5. SYDENHAM CHOREA/ ST. VITUS DANCE – Involuntary, purposeless movts of extremities accompanied with facial grimacing, speech disturbance, emotional lability and muscle weakness – Exaggerated with anxiety and relieved with sleep • 6. ASCHOFF BODIES – Inflammatory, hemorrhagic, bullous lesions causing swelling, fragmentation and alterations in connective tissues – Found in heart (mitral valve), blood vessels, brain, serous surfaces of joints and pleura RHD: MINOR SIGNS AND SYMPTOMS • Arthralgia (joint pain) • Low-grade fever that spikes in late pm • Diagnostic tests – Antibody

– – –

• • • •

•

C-reactive protein ESR

ASO titer ( 7 days after infection, max. levels in 4-6 wks) Streptolysin- Streptococcus extracellular product that lyses RBC O- oxygen labile ASO- concentration of Ab formed in blood against the product N= 0-120 Todd units abN= 333 Todd units (+) RHD

RHD: JONES CRITERIA • Diagnosis of RHD – 2 MAJOR OR – 1 MAJOR + 2 MINOR + HX OF STREP/SORE THROAT RHD: MANAGEMENT • Bed rest (not strict) • Avoid contact sports • Aspirin: anti-inflammatory, analgesic – Not given to pt with viral infection; at risk of Reye’s Syndrome (encephalopathy with fatty infiltrates on liver and brain) • C/S by throat swab • Prophylactic antibiotics to prevent recurrence – Pen G IM monthly or Erythromycin (if allergic to Pen G) – Pen V po or Sulfadiazine po – Duration is uncertain, usually long-term because pt is at risk of bacterial endocarditis • Given 1 hr prior to dental, surgical procedure

32 aoih0718

Pedia RESPIRATORY RATE Normal Values AGE NEWBORN 1 YR 2-3 YRS 5 YRS 10 YRS 15 YRS AND ABOVE

RATE/MINUTE 40-60 20-40 20-30 20-25 17-22 12-20

BREATH SOUNDS SOUNDS Vesicular Broncho-vesicular Bronchial Rhonchi Rales Expiratory Wheezing Inspiratory Stridor Resonance Hyper-resonance

CHARACTERISTICS Soft, low-pitched, heard over lung periphery, I>E, N Soft, medium-pitched, heard over major bronchi, I=E, N Loud high-pitched, heard over trachea, I<E, N Snoring sound made by air moving through mucus in bronchi, N Crackles (like cellophane) made by air moving through fluid in alveoli, abN: denotes pneumonia, which is fluid in alveoli Whistling on expiration made by air being pushed through narrowed bronchi, abN: seen in children with asthma or foreign-body obstruction Crowing or roosterlike sound made by air being pulled through a constricted larynx, abN, seen in infants with respiratory obstruction Loud, low tone, percussion sound over normal lung tissue Louder, lower sound than resonance, a percussion sound over hyperinflated lung tissue

RESPIRATORY DISTRESS SYNDROME • Or Hyaline Membrane Disease • Due to lack of surfactant (developed at 7 mos AOG, N Lecithin: Sphingomyelin ratio= 2:1; indicates fetal lung maturity) • There is fibrin around alveoli→ atelectasis, hypoxia and acidosis • Diagnosis is definite during 4 hrs of life • Signs and Symptoms (see Silverman Anderson Index) – RR – Nasal flaring – Expiratory grunting (major S/) – Retractions (earliest S/) • Supraclavicular • Suprasternal • Intercostal • Substernal • Subcostal • Xiphoid • Management • Elevate head, with neck slightly extended (Open airway) • Proper suctioning (Clear airway) • O2 administration with humidity (lowest O2 concentration possible) • Place on CPAP/ PEEP to maintain alveoli partially open (to prevent collapse) • Monitor VS, skin color and ABG • Chest physiotherapy • Percussion: use padded small plastic cup or small O2 mask • Vibration: use padded electric toothbrush • Administer surfactant replacement therapy via intratracheal route • Instill thru catheter inserted into ET • Avoid suctioning for at least 2 hours after • WOF ↓HR and desaturation LARYNGOTRACHEOBRONCHITIS • Most common form of croup • Due to viral or bacterial infection 33 aoih0718

Pedia • •

• • •

• • •

Gradual onset, may be preceded by URTI Signs and Symptoms • Fever • Irritability and restlessness • Anorexia, N/V • Inspiratory stridor • Suprasternal retractions • Seal bark and brassy cough • Hoarseness • Crackles, wheezes • Intermittent and permanent cyanosis (Late Sign) Laboratory studies • ABG: respiratory acidosis • Throat culture Diagnostic Studies • Chest and neck X-ray to r/o epiglotitis Management • Maintain patent airway • Place child in cool, humidified mist O2 tent as ordered • WOF pallor or cyanosis • Elevate head of bed; provide bed rest Encourage fluid intake (via IV if on NPO) Prepare intubation set at bedside Administer meds as ordered • Antipyretic • Antibiotic • Nebulization • Racemic epinephrine • Bronchodilator • Corticosteroid • *Avoid cough syrups & cold meds (thicken and dry secretions)

BRONCHIOLITIS/ RSV • Production of thick, tenacious mucus, due to Respiratory Syncytial Virus (RSV)- via direct contact • Signs and Symptoms • Cold/flu-like Sx • Poor feeding, lethargy, irritability • RR- Sign of developing RDS • Nasal flaring and retractions • Expiratory wheeze and grunt • Diminished breath sounds • Management • Maintain patent airway • Position: 30-40 degree angle with neck slightly extended to open airway and ↓ pressure on diaphragm • Provide cool, humidified O2 as ordered • WOF dehydration: encourage fluids (via IV if on NPO) • Isolate the child in single room or with another child with RSV • Strict handwashing • Administer meds as ordered: • Anti-viral: Ribavirin (Virazole) via aerosol by hood, tent, mask or ventilator tubings • RSV IgIV (RespiGam) or palivizumab (Synagis) EPIGLOTTITIS • Emergency of all URTI • Cx of bronchiolitis • Bacterial form of croup (S. pneumoniae or H. influenzae type B) • Sudden/acute onset, usually in winter • Common among 2-5 years of age • Signs and Symptoms • High fever • Sore, red, inflamed throat 34 aoih0718

Pedia

• •

• (-) cough • Drooling • Dysphagia • Muffled voice • Inspiratory stridor • Agitation Classic Sign • Tripod Position: leaning forward with tongue protrusion Management • Avoid tongue depressor, oral thermometer, laryngoscopy, throat swab • Prepare trache set not ET set • Place pt inside cool Mist tent or Croupette with high humidification (to reduce airway swelling) • Give plastic, washable toys • No toys causing friction→ O2 supports combustion • Tuck edges properly • Maintain on NPO • Don’t restrain the child or force to lie down • Administer antipyretics and antibiotics as ordered • Ensure up-to-date Hib conjugate vaccination

PNEUMONIA • Inflammation of the alveoli • Causative agents – Virus – Mycoplasma – Bacteria – Aspiration of foreign substance • Signs and Symptoms – Acute onset, fever – Infant: irritability, lethargy, poor feeding, abrupt fever with seizures, RR distress (air hunger, tachypnea, cyanosis) – Older child: HA, chills, abdominal & chest pains – Hacking, nonproductive cough→ purulent sputum •

– ↓ breath sounds or scattered crackles, wheezes Management – Bed rest, lie on affected side (splinting) – Antimicrobial therapy – Antipyretic as ordered – Cool, humidified O2 (cannula, hood, mist tent) as ordered – Liberal fluids – Chest physiotherapy and suctioning – Isolation precautions for Staph or Pneumococcal pneumonia – Thoracentesis

ASTHMA • Chronic, inflammatory disease of the airways • Common causes – Foods, pollens, dust mites, cockroaches, smoke, animal dander, T changes, respiratory infection, activity, stress • Status asthmaticus – A medical emergency, RR failure and death can ensue – RR distress despite vigorous treatment • Signs and Symptoms – Expiratory wheezing, breathlessness, tachypnea, dyspnea, chest tightness, esp. at night and early am – Hacking, nonproductive cough→ frothy, clear gelatinous sputum – Cyanosis, diaphoresis, retractions – Chest hyperresonance on chest percussion – (-) breath sounds with tachypnea: ventilatory failure and asphyxia • Management – Eliminate allergens – Avoid extremes of T and exposure to viral respiratory infection 35 aoih0718

Pedia – – – – – –

Recognize early Sx of an asthma attack Adequate rest, sleep, well-balanced diet, fluid intake, exercise Annual flu vaccine Chest physiotherapy Use of nebulizer, meter-dose inhaler, cleaning of devices (to prevent oral candidiasis) Administer meds as ordered • Bronchodilators • β 2 agonist (Salbutamol, Albuterol) • Racemic epinephrine • Corticosteroids • Antiallergic meds • NSAIDs

BLOOD PRESSURE • Normal values • < 1yr: 87-105/ 53-66 • Estimation of Systolic BP (lower limit): 70 mmHg + (2 X age in yrs) • A fall in 10 mmHg: consider shock AGE SYSTOLIC Birth (12 hrs, < 1kg) 39-59 Birth (12 hrs, 3kg) 50-70 Neonate (96 hrs) 60-90 Infant (6 mos) 87-105 Toddler (2 yrs) 95-105 School age (7 yrs) 97-112 Adolescent (15 yrs) 112-128 •

DIASTOLIC 16-36 25-45 20-60 53-66 53-66 57-71 66-80

Cuff should cover 2/3 of arm – Large cuff: false low BP – Small cuff: false high BP

SKIN • Acrocyanosis- body pink, extremities blue • Generalized mottling due to immaturity of the circulatory system MONGOLIAN SPOTS • slate-gray or bluish discoloration/patches commonly seen across the sacrum or buttocks • Due to melanocytes accumulation • Common among Asians • Disappears by 1 yr or to school age period MILIA • Plugged/unopened sebaceous glands • White pinpoint patches on nose, chin, cheek • Disappears by 2-4 wks LANUGO • Fine downy hair covering the shoulders, back, upper arm • Common in preterms • Disappears in 2 wks DESQUAMATION • peeling of the NB skin within 24 hrs • Common in post terms • Extreme dryness beginning at soles and palms STORK BITES • Or Telangiectasi nevi • Pink patches at the nape of the neck • Disappears when child grows ERYTHEMA TOXICUM • Or Flea-bite rash • 1st self-limiting rash • Appears sporadically and unpredictably as to time and place HARLEQUIN SIGN • dependent part is pink, independent part is blue, because of the tendency of RBC to go down 36 aoih0718

Pedia CUTIS MARMORATA • Transitory mottling of the skin when exposed to cold HEMANGIOMAS • vascular tumors of the skin • 3 Types 1. Nevus Flammeus (Portwine Stain) -macular purple or dark red lesions usually seen on the face or thigh • Never disappear, can be removed surgically 2. Nevus vasculosus (Strawberry hemangiomas)- dilated capillaries in the entire dermal or subdermal area continuing to enlarge but disappear after 10 years old 3. Cavernous hemangiomas- consist of communicating network of venules in the subcutaneous tissue that never disappear with age • Most dangerous type, may lead to internal hemorrhage or aneurysm VERNIX CASEOSA • White, cheese-like substance for lubrication • Insulator and bacteriostatic • If yellow: hyperbilirubinemia SKIN COLOR’S SIGNIFICANCE • Blue: cyanosis (hypoxia) • White: edema • Pale: anemia • Yellow: carotenemia or jaundice • Gray: infection, sepsis BURN TRAUMA • injury to body tissue cause by excessive heat HIGH RISK BURN VICTIM: CHILD • Higher proportion of body fluid to smaller muscle & fat mass, thinner skin→ Higher mortality r/t – Fluid & heat loss – Dehydration – Metabolic acidosis – Cardiovascular collapse – Protein & calorie deficiency – Infection MODIFIED RULE OF NINES ASSESSMENT OF EXTENT (INFANTS) PARTS

ANTERIOR 9.5 1 2 1.5 1.25 13 13 1 2.5 2.75 2.5 1.75

POSTERIOR 9.5 1 2 1.5 1.25 2.75 2.5 1.75

PARTS

ANTERIOR 6.5 1 2 1.5 1.25 13 13 1 2.5 4

POSTERIOR 6.5 1 2 1.5 1.25 4

Head Neck Upper Arm Lower Arm Hand Trunk Back Genital Each Buttock Thigh Leg Foot 5-9 YEARS Head Neck Upper Arm Lower Arm Hand Trunk Back Genital Each Buttock Thigh

37 aoih0718

Pedia Leg Foot

3 1.75

3 1.75

ASSESSMENT OF DEPTH • 1ST Degree (Superficial Thickness) – involves only the superficial epidermis characterized by erythema, dryness and pain – Example: Sunburn – Heals by regeneration by 1-10 days • 2ND Degree (Partial Thickness) – involves the entire epidermis, and portion of dermis characterized by erythema, blistered and moist from exudates which is extremely painful – Example: Scalds – Heals by regeneration by 4-6 wks • 3RD Degree (Full Thickness) – involves both skin layers, epidermis and dermis/may involve adipose tissue, fascia, muscle and bone – appears leathery, white or black and not sensitive to pain since nerve endings had been destroyed – Example: Lava, flame burns Management 1. First aid – Put out flames by rolling the child on a blanket – Immerse the burned part on a cold water – Remove burned clothing – Cover burns with sterile dressing 2. Maintenance of a patent airway – Suction secretions prn – O2 administration with humidity – Tracheostomy or ET intubation 3. Prevention of Shock, Fluid and Electrolyte Imbalance – Isotonic saline or LR to replace electrolytes – Colloids to expand blood volume – Dextrose in water to provide calories FLUID RESUSCITATION: PARKLAND FORMULA • Plain LR 4ml X body wt (kg) X TBSA burned – ½ of total: 1st 8hrs post burn – ¼ of total: 2nd & 3rd 8hrs post burn • Goal: U.O.= 1ml/kg/hr 4. Booster dose of tetanus toxoid 5. Relief of pain such as IV analgesic (Morphine SO4) 6. Prevention of wound infection – Wound cleaning and debriding – Open and close method of wound care – Whirlpool treatment 7. Skin grafting: From buttocks or xenograft, frozen cadaver 8. Diet: calorie, protein ATOPIC DERMATITIS • Or Infantile eczema (2-6mos. of age) • Papulovesicular erythematous lesions with weeping or crusting • Due to food allergens – Milk, eggs, citrus juices, tomatoes, wheat • Signs and Symptoms – Extreme pruritus – Linear excoriation (due to scratching) – Lichenification (scaly, shiny white skin) • Management – Avoid food allergens – Give Isomil or Prosobi (hypoallergenic milk) – Hydrate skin with Burowl’s solution – Topical steroid (1% hydrocortisone cream) – Topical antihistamine 38 aoih0718

Pedia • • • • •

Skin care: avoid skin irritants (soap, detergent, fabric softener, diaper wipes, powder) Apply cool, wet compress to soothe skin Proper hygiene: hand washing, nail cutting Minimize scratching: place gloves/mittens over hands Avoid heat, woolen clothes/blankets, rough fabrics, furry stuffed animals

IMPETIGO • Highly infectious, caused by Group A β -hemolytic Streptococcus, possibly Staph aureus • Predisposing factor: heavy infestation of Pediculosis capitis then pick nose • Papulovesicular lesions (face, around mouth, hands, neck, extremities) surrounded by localized erythema becoming purulent and ooze, forming a honey-colored crust • Cx: AGN • Management • Contact isolation (Communicable for 48hrs without treatment) • Skin care – Allow lesions to dry by air exposure – Daily bathing with antibacterial soap (pHisoHex) – Warm compress 2-3X/day to remove crusts – Use of skin emollients to prevent cracking • Proper hygiene – Strict handwashing – Use separate towels, linens, dishes (washed separately with detergent in hot water) • Oral antibiotics (Penicillin) • Antibiotic ointment (Mupirocin) PEDICULOSIS CAPITIS (HEAD LICE) • Infestation of hair and scalp with lice • Sites affected: occipital area, behind ears, nape, eyebrows & lashes • Transmitted by direct and indirect contact (sharing brushes, hats, towels & bedding) • All contacts should be treated • Signs & Symptoms – Intense pruritus – (+) adult lice (gray specks crawling fast) – (+) silver/gray specks firmly attached to hair shaft • Management – Pediculicide shampoo & repeat after 7days – Permethrin (Nix) rinse • Apply to washed, towel-dried hair, leave for 10 mins, rinse • Remove nits with fine-toothed comb – Change bedding & clothing OD, wash in hot water with detergent, hot dryer for 20mins – Seal non-essential bedding, clothing, unwashable toys in plastic bag for 2wks – Discard hairbrushes/combs or soak in hot water – No sharing of bedding, clothing, headwear, hairbrush/comb – Vacuum furniture & carpets frequently SCABIES • Infestation of Sarcoptes scabiei (itch mite) • F mite burrows into epidermis, lay eggs & dies after 4-5 wks • The eggs hatch in 3-5 days, larvae mature & complete life cycle • Contagious during course of infestation via direct contact • Signs & Symptoms – Intense pruritus esp. at night – (+) burrows (fine grayish red lines) on skin • Management • Topical scabicides: – Lindane cream (Kwell, Scabene) should not be used for <2 y/o: risk of neurotoxicity and seizures; Crotamiton (Eurax) • Warm soap-and-water bath • Dry and cool skin • Apply scabicide lotion; leave for 8-14 hrs before rinsing – Permethrin 5% (Elimite): cream is massaged thoroughly and gently from head to soles; avoid contact with eyes • Treat all household members & close contacts 39 aoih0718

Pedia • • •

Strict handwashing Change all clothing & bedding OD, wash in detergent with hot water, hot dryer & iron before reuse Seal nonwashable toys & other items in plastic bag for 4 days

ACNE VULGARIS • Self-limiting, inflammatory skin disease involving sebaceous glands • Common among adolescents • Sign: Comedones: composed of sebum (lipids) causing whiteheads • Management • Proper hygiene • Use mild sulfur (antibacterial) soap • Anti-acne cream (Tretinoin, Retin-A) HEMOLYTIC DISORDERS: ANEMIA • Causes – Early cutting of cord • Term- should be cut until pulsation stops (60-100 cc) • Preterm- cut at once to prevent jaundice – Bleeding disorders (Blood dyscrasia) IRON DEFICIENCY ANEMIA • ↓ iron stores needed for Hgb production

• •

• •

Caused by blood loss, metabolic demands, GI malabsorption, ↓ iron in diet S/Sx: pallor, weakness & fatigue, irritability iron diet (dark, green leafy vegies, breads, cereals, egg yolk, kidney beans, liver, meat, raisins) Administer iron supplements as ordered • In between meals • With Vit. C/citrus juice: absorption

• • •

Milk/antacids: ↓absorption Liquid iron: Taken with straw or medicine dropper at the back of mouth S/E: foul aftertaste, melena, constipation

HEMOPHILIA • X-linked recessive • 3 Types – Hemophilia A: deficient clotting Factor VIII (classic) – Hemophilia B: deficient clotting Factor IX (Christmas disease) – Hemophilia C: deficient clotting Factor XI Signs and Symptoms • Sudden bruising when child grows (earliest sign) – Delayed diagnosis at birth because NB received maternal clotting factors – Major sign: Hemarthrosis- bleeding/damage to synovial membrane • abN bleeding in response to trauma or surgery • N: bleeding time, PT, platelet count; abN: PTT Management • Monitor bleeding: hematuria, IC bleed (neuro status) • Bleeding precautions: – Avoid contact sports (swimming is preferred) or if anticipated, wear protective devices (helmets, knee & elbow pads) – Ask pt if hemophiliac before doing any invasive procedures – Use smaller gauge needle • Immobilize and elevate bleeding extremity, apply gentle pressure (15 mins) and cold compress • Administer factor VIII concentrate or desmopressin (DDAVP) as ordered LEUKEMIA • Group of malignant disease • Rapid immature WBC, competes nutrition with mature WBC and production of RBC and platelets • N= 500 RBC: 1 WBC CLASSIFICATION OF LEUKEMIA • Lympho- affects lymphocytes • Myelo- affects myeloblasts 40 aoih0718

Pedia • Acute/Blastic- affects immature cells • Chronic/Cystic- affects mature cells • Most common in children: Acute Lymphocytic Leukemia (ALL), peak onset 2-6 y/o, M>F • Acute Myelogenous Leukemia (AML): peak onset 15-39 y/o Signs and Symptoms • From invasion of BM • Infection: T, poor wound healing, sore throat, bone weakens→ fracture, bone & joint pains, lymphadenopathy • Bleeding: hemorrhage, petechiae, epistaxis, hematoma, hematuria, hematemesis, hepatosplenomegaly • Anemia: pallor, fatigue, anorexia, constipation • From invasion of CNS • ICP: ↓LOC, severe HA, vomiting, papilledema, seizures • CN VII or spinal nerve involvement • From invasion of kidneys, testes, prostate, ovaries, GI and lungs Diagnostic Tests • PBS- (+) immature WBC • CBC- immature WBC, ↓ RBC, ↓ platelets • Done weekly during maintenance phase of chemotherapy • Lumbar Puncture- CNS affectation • Shrimp/fetal/C-position, avoid neck flexion may occlude airway of infants and children Triad Management • Surgery (most preferred) • (Cranial) Irradiation • Chemotherapy • BM transplant 4 LEVELS OF CHEMOTHERAPY • 1. For Induction – To achieve complete remission (disappearance of leukemic cells) – Meds: Oral Prednisone Vincristine and L-asparaginase IV • 2. For Sanctuary – To treat leukemic cells that invaded testes and CNS – Meds: Intrathecal Methotrexate • 3. For Maintenance – To continue remission – Meds: Oral Methotrexate, 6-Mercaptopurine and Cytarabine • 4. For Reinduction – To treat leukemic cells after relapse occurs *Antigout agents: Allopurinol (Zyloprim) to treat/prevent hyperuricemic nephropathy (force fluids) NURSING MANAGEMENT • Assess for common side effects: anorexia, nausea and vomiting (give antiemetics 30mins prior to chemo and continue until 1 day post chemo), WOF dehydration • Assure pt that alopecia and hirsutism are temporary side effects, hair will regrow in 3-6 mos. With new color & texture • Assess for stomatitis (oral ulcers) – Oral care: alcohol-free mouthwash, pNSS with or without NaHCO3 – Use soft-bristled toothbrush, cotton plegets – Apply Xylocaine (topical anesthetic) on mouth before meals – Diet: soft and bland according to child’s preference, small frequent feedings • Protect pt from infection – Strict hand washing – Reverse isolation • Protect pt from additional fatigue – Bed rest – Activities balanced with rest • Protect pt from bleeding – Minimize parenteral injections – Apply pressure on venipuncture sites – Use electric razor in shaving • Encourage verbalization of feelings & concerns • Introduce the family to other families of children with CA 41 aoih0718

Pedia •

Consult social services & chaplains as necessary

NEPHROBLASTOMA (Wilm’s Tumor) • Tumor of the kidney (uni- or bilateral) with metastasis to other organs • Peak incidence: 3 y/o • Treatment: Partial to total nephrectomy & chemotherapy with or withour radiation Signs & Symptoms • Mass within abdomen (firm, nontender, confined to 1 side & deep within the flank) • Abdominal pain • Urinary retention, hematuria • Anemia (r/t tumor hemorrhage), pallor, anorexia, lethargy • HTN (r/t renin production by tumor)

•

Weight loss, T • Lung involvement: dyspnea, chest pain Management • Monitor VS, esp. BP • Place a sign “DO NOT PALPATE ABDOMEN” at bedside • Measure abdominal girth • WOF abdominal distention, ↓bowel sounds because of risk of GI obstruction post op RH INCOMPATIBILITY • Or Isoimmunization • Rh (Rhesus factor)- 85% of population: foreign body: Antigen: protein factor • Happens if: – Mother Rh (-) – Father/Fetus Rh (+) • 4th child is severely affected r/t degree of sensitization to Rh (+) RBC • Fetus: Erythroblastosis fetalis – IUGR due to hemolysis – Pathologic jaundice within 24hrs – Hemolytic anemia (↓ O2-carrying capacity): • Cardiac decompensation • Hydrothorax • Hepatosplenomegaly • Edema, ascites Diagnostic Tests • Indirect Coomb’s test – Maternal serum mixed with Rh(+) RBC – In mother with Rh (-): clumping (+) result • Direct Coomb’s test – Neonatal cord blood washed and mixed with Coomb’s serum – Fetus with Rh (-): clumping (+) result Preventive vaccine: Rho gam IM – Given to Rh(-) mother, NEVER TO BABY, at 28 wks AOG and within 72 hrs post delivery, BT, amniocentesis, chorionic villi sampling, D & C, abortion – Purpose: to destroy fetal Rh (+) RBC and prevent sensitization – S/E: fever, pain at injection site – CI: allergy to human Ig ABO INCOMPATIBILITY • Happens when: – Mother blood type O – Fetus: A, B, AB • O-A most common • O-B most severe • 1st child can be severely affected

42 aoih0718

Pedia

Blood RB Group A • • •

•

•

Upon uterine contraction: start of hemolysis Fetus: Hydrops fetalis – Edematous, lethal state with pathologic jaundice Management – No breastfeeding • Has Pregnanediole: delays action of glucoronyl transferase (liver enzyme that converts indirect to direct bilirubin) otherwise, complication: Kernicterus (irreversible brain death) Use of Phototherapy Exchange Transfusion for Rh or ABO affectations cause continuous ↓ in Hgb during the first 6 months because the BM fails to produce erythrocytes in response to continuing hemolysis

JAUNDICE • Hyperbilirubinemia – N= 0-3 mg/dl indirect bilirubin – >12 mg/dl (full terms) • Kernicterus (Bilirubin Encephalopathy) – >20 mg/dl (full terms) – >12 mg/dl (preterms, because liver is immature) – May lead to cerebral palsy • Physiologic Jaundice (Icterus Neonatorum) – Onset: 2nd to 7th day of life, for 48-72 hrs – Management: exposure to early AM sunlight • Pathologic Jaundice – Onset: within 24 hrs, for > 1-2 wks • Breastfeeding Jaundice – Due to pregnanediole • Assessment – Blanching the forehead, nose or sternum – Normal finding: cyanosis – Light stool, dark urine, yellow sclerae • Management: Phototherapy or Photooxidation 18-20 in. far from NB • Use of intense florescent lights to ↓ serum bilirubin levels • Injury from treatment e.g. eye damage, dehydration or sensory deprivation can occur • Cover the eyes (to prevent retinal damage, corneal dryness)

AB 43 aoih0718

A,

Pedia • •

• • • • • •

•

Cover genitals (to prevent PRIAPISM: painful continuous penile erection) Change position q2h (for even exposure) fluid intake (to prevent dehydration) Monitor I&O – Best: weigh the baby – Weigh the diaper: 1g= 1cc Monitor VS Avoid lotion or oil to skin (to prevent burns) Expect bright green urine & stool (loose) Transient S/E: bronze baby syndrome AbN ↓ blood glucose

– –

•

• • HEAD  

↓ 30mg/dl in 1st 72hrs or

↓ 45mg/dl after 1st 3 days of life N blood glucose: – 40-60mg/dl: 1 day-old – 50-90mg/dl: 1 day-old S/Sx: RR, twitching, tremors, cyanosis, unstable T, lethargy, poor muscle tone Mgt: early feedings (po or IV as ordered) ¼ (25%) the entire body length Structures  Sutures: sagittal, coronal, lambdoidal  Fontanels: 6, 2 are palpable (Anterior and Posterior)

Anterior Fontanel (Bregma)  Diamond-shaped  N=3X4 cm, closes at 12-18 mos  > 5 cm: hydrocephalus  Premature closure: Craniostenosis or Craniosynostosis  Small, slow growing brain: Microcephaly  (-) cerebral hemisphere: Avencephaly Posterior Fontanel (Lambda)  Triangular shape  N=1X1 cm  Closes at 2-3 mos STRUCTURES OF THE HEAD CRANIOTABES  Localized softening of the cranial bones among NB  Common to 1st born due to early lightening  In older child: a sign of Ricketts (Vit D deficiency)- night sweats at head part CAPUT SUCCEDANEUM  Edema of the scalp due to prolonged pressure at birth  Present at birth  Crosses suture lines  Disappears after 2-3 days (water absorbed easily) CEPHALHEMATOMA  Collection of blood due to ruptured periosteal capillaries r/t trauma  Present after 24hrs  Doesn't cross suture lines  Disappears after 4-6 wks (WOF jaundice) SEBORRHEIC DERMATITIS  Or Cradle Cap  Scaling, greasy-appearing, salmon colored patches usually seen on the scalp, behind ears and umbilicus  Due to improper hygiene 44 aoih0718

Pedia 

Mgt: apply coconut/baby oil the night before shampooing the next day

HYDROCEPHALUS • CSF production > absorption • Causes – Malformations – Tumors – Hemorrhage – Infection – Trauma • 2 types – Communicating (Extraventricular) r/t impaired CSF absorption – Non-communicating (Intraventricular)- r/t CSF flow obstruction Early Signs and Symptoms • ↓ LOC • AbN large head >35 cm (N by 1-2 yrs, HC=CC; measure HC until 2 yrs) • Bulged/tensed fontanel • Cracked-pot sound on percussion: Macewen’s sign • Dilated scalp veins • Projectile vomiting: surest sign of cerebral irritation • Frontal Bossing: prominent forehead • Sunset eyes • Headache, dizziness, vertigo • Diplopia • Change in pupilary response and equality Late Signs and Symptoms • High-pitched, shrill cry • Seizures • Cushing’s triad: BP with widened pulse pressure, ↓ HR, ↓ RR • Decorticate and decerebrate posturing • Fixed and dilated pupils Management • Position: low semi-fowler's (head at 30-45 degree angle and at midline) • Mannitol- osmotic diuretic • Acetazolamide- to decrease CSF production • Diazepam/Phenobarbital- anticonvulsants Surgery • VP (Ventriculoperitoneal) shunt – CSF drains into peritoneal cavity from lateral ventricle • AV (Atrioventricular) shunt – CSF drains into R atrium from the lateral ventricle – Used for older children and with pathological conditions of the abdomen Post-op Management • Sidelying position on non-operative side to prevent pressure on the shunt valve • Keep child flat as prescribed to avoid rapid reduction of CSF • If ICP occurs, elevate head of bed 15-30 degrees to enhance gravity flow to the shunt • Sign of good drainage: sunken fontanel • If blocked/obstructed: bulging fontanel • Shunt is changed as the child grows • WOF and prevent infection MENINGITIS  CNS infection caused by bacteria or viruses  May be acquired as a complication of neurosurgery, trauma, infection of the sinus, ears or systemic infections  Diagnosis: CSF analysis via Lumbar Puncture (LP): insertion of spinal needle thru the L3-L4 interspace under strict asepsis

    

Contraindication: ICP→ brain herniation Preparation: informed consent, pt on empty bladder Collect and label specimens in sequence Force fluids post procedure as ordered Positions: 45 aoih0718

Pedia  

During LP: C-position, fetal or shrimp: knees flexed up to abdomen, head bent, chin to chest After LP: flat on bed for 4-12 hrs as prescribed

 CSF shows pressure, cloudy, CHON, ↓glucose Signs and Symptoms:  Fever, chills  Vomiting, diarrhea  Anorexia High-pitched cry  Bulging fontanels    

↓ LOC Muscle joint pain Petechial or purpuric rashes (meningococcal infection) Kernig’s sign: pain and spasm of hamstring when thigh and knee are flexed



Brudzinki’s sign: head flexion→ knee and hip flexion

Management  Isolation for at least 24hrs after antibiotics are initiated  Administer antibiotic as ordered  Monitor neuro VS, I/O, nutritional status  Determine child’s close contacts for prophylactic treatment SENSES  Sense of Sight (Eyes)  Sclera  N: bluish-gray, white  AbN: subconjunctival hemorrhage (t/c Shaken Baby Syndrome)  Pupils  N: PERLA, round  AbN: Coloboma- absence of part of iris  AbN: Congenital cataract: Rubella exposure while in utero  Cornea  N: bright, shiny, corneal reflex to touch, (+)blink reflex, round and adult-sized  Retina  abN: Retinoblastoma (tumor)  Mgt: Enucleation  Test for Blindness for Infant and Children  Doll's test:  N: when head is turned, eye movement lags behind  AbN: if beyond 10 days  Glabellars or Myerson's Test:  Tap over forehead, bridge of nose or maxilla  N: blinks for 1st 4-5 taps  Test for Blindness for School age and Adolescents  Tonometry  Snellen's Chart  N: eyes cross because of weak EOMs  N: eyelids edematous r/t pressure during birth & effects of eye meds  Sense of Smell (Nose)  Normal findings (Neonate/Infant)  At midline, appears large for the face  Apparent lack of bridge, flat, broad  Some mucus but (-) discharge  Obligatory nose breathers  Sneezes  Abnormal findings (Neonate/Infant)  Malformed  (+) alar flaring (RDS)  Copious discharge 46 aoih0718

Pedia With or without cyanosis, return to pink when crying (Congenital syphilis or Chromosomal disorders) Sense of Hearing (Ears)  1st sense to develop and last sense to disappear  N: firm cartilage with recoil  N: aligned with outer canthus of eyes  Abnormal finding: LOW-SET EARS  Kidney malformation  Renal Agenesis: unilateral and bilateral (dangerous  Mgt: Kidney transplant  Chromosomal aberration 



DEVELOPMENTAL DEFECTS  Multifactorial: disease requiring both genetic predisposition and environmental condition  Ex: Arthritis, DM, HD  Single gene defect  Dominant inheritance  Polydactyly  Huntington's disease (NS degeneration)  Chronic/Simple glaucoma  Recessive inheritance  PKU  Thalassemia  Sickle-cell anemia (Mediterranean Jews)  X-linked  Color blindness  Hemophilia CHROMOSOMAL ABERRATION  Nondisjunction: uneven division resulting 45 and 47 chromosomes (abN structure and number of chromosomes)  Trisomy 21 (Down's Syndrome/ Mongolism): most common type  Extra chromosome 21  Karyotype: 47 XX+ 21 or 47 XY+21  Predisposing factor: maternal age >35, paternal age >45 DOWN’S SYNDROME  Signs and Symptoms  Low set ears  Mongolian eyes: slanted eyes  Broad, flat nose  Protruding tongue  Puppy neck  Simean crease: single transverse line on palm  Hypotonia: at risk for URTI  MR: from educable to needing institutionalization EDWARD’S SYNDROME  Or Trisomy 18  Karyotype: 47 XX+18 or 47XY+18  Signs and Symptoms  Rocker’s Bottomfoot: Sole of foot rounded  Misshapen fingers and toes PATAU’S SYNDROME  Or Trisomy 13  Karyotype: 47 XX+13 or 47XY+13  Signs and Symptoms  Micropthalmia 47 aoih0718

Pedia 

Eye agenesis

TURNER’S SYNDROME  Or Monosomy of X chromosome  Karyotype: 45 XO with vagina  Signs and Symptoms (seen only during puberty)  Poorly developed female secondary sex characteristics  Sterile: Mgt: HRT (Estrogen) KLINEFELTER’S SYNDROME  Or Trisomy of X chromosome  Karyotype: 47 XXY with penis  Signs and Symptoms (seen only during puberty)  Poorly developed male secondary sex characteristics  Voice not deep, gynecomastia  Sterile: Mgt: administration of androgen 









Deletion Abnormalities: part of chromosome breaks during cell division resulting 45 ¾ chromosomes  Cri-du-chat Syndrome: 46 XX5g (5th chromosome in defect)  Fragile X Syndrome Translocation Abnormalities: normal count of chromosome but structural arrangement is different  Balanced Translocation Carrier  Unbalanced Translocation Syndrome Mosaicism: a situation wherein the nondisjunction of chromosomes occurs during the mitosis after fertilization resulting to different cells contains different numbers of chromosome  Some cells are N, some abN  Better prognosis, has no severe mental defect  Associated with teratogens Isochromosomes: a situation wherein the chromosome instead of dividing vertically it divides horizontally resulting to chromosomal mismatch Sense of Hearing (Ears)  Abnormal finding: (+) yellowish, foul-smelling discharge

OTITIS MEDIA: infection of middle ear  Predisposing Factors  Shorter, wide, straight and narrow Eustachian tube in children  Bottle propping  Cleft lip and/or palate  Signs and Symptoms  Milky, purulent foul-smelling discharge  Pain on pulling pinna  S/Sx of URTI: cough, colds, fever  Otoscopic exam: red, opaque, bulging tympanic membrane, (-) light reflex  Management

    

 

fluid intake, feed child in upright position, avoid chewing gums to ↓ pain Apply local heat Side-lying position on affected side to drain discharges Clean discharges with sterile cotton swabs Administer meds as ordered:  Antipyretic for fever  Antibiotics for 10-14 days: Amoxicillin, Ampicillin (Cx: Bacterial meningitis)  Ear drops Hearing loss screening is important Surgery: Myringotomy with Tympanostomy tube insertion  To equalize pressure and to keep the ear aerated  Maintained until the tubes fall off or after 6 mos. to prevent permanent hearing loss  Pt should keep ear dry, wear earplugs durign bathing, shampooing and swimming; avoid diving and submerging under water 48 aoih0718

Pedia MOUTH AND TONGUE  Mouth: symmetrical, opens evenly when crying  Tongue: appears large, symmetrical  Soft and hard palates intact  Uvula in midline TONSILLITIS & ADENOIDITIS  Inflammation or infection of tonsils and adenoids  Signs & Symptoms  Recurrent sore throat (cough, fever)  Enlarged, bright red tonsils with white exudate  Difficulty swallowing  Mouth breathing; unpleasant mouth odor  Enlarged adenoids: nasal speech, difficulty hearing, snoring or obstructive sleep apnea PRE-OP MANAGEMENT  Assess for signs of  Active infection  Bleeding (check clotting studies) because the throat is vascular  Loose teeth to prevent aspiration  Prone or side-lying position  Don’t suction unless there is airway obstruction  WOF hemorrhage (frequent swallowing)  Avoid coughing or clearing of throat  Give clear, cool noncitrus, noncarbonated drinks, avoid red liquids (masks bleeding) and milk (covers throat)  Avoid using straw, fork or sharp objects  Pain meds as ordered BELL’S PALSY • Facial Nerve Paralysis (CN VII Injury) due to forceps delivery • Self-limiting • Signs and Symptoms – Continuous drooling – Inability to open one eye and close the other eye • Apply artificial tears TRACHEOESOPHAGEAL FISTULA/ATRESIA  (-) connection of esophagus to stomach, may have connection to trachea  Aspiration pneumonia, severe RR distress and death may ensue without surgical intervention  A surgical emergency (placement of cervical esophagostomy and gastrostomy tube)  Signs and Symptoms (4C’s)  Coughing  Choking  Cyanosis  Continuous drooling POST OP MANAGEMENT: TEF Prevent aspiration  Upright or prone position  Suction oral & nasopharyngeal secretions  Keep double lumen cath in upper esophageal pouch attached to low-pressure suction; irrigate with pNSS to prevent clogging  Keep G-tube open to drain (for 5-7d)  Support nutritional status  Progressive small, frequent G-tube feeding with sterile water to breastmilk/formula  If with cervical esophagostomy, offer pacifier Prevent skin breakdown  Assess cervical esophagostomy site for redness, exudate  Remove drainage frequently  Apply protective ointment, barrier dressing or collection device 49 aoih0718

Pedia EPSTEIN PEARLS  N among NB  1-2, small, round, glistening white cysts seen at the palate or gums r/t hypercalcemia while in utero NATAL TOOTH • Rootless, tooth at the moment of birth r/t hypervitaminosis while in utero • Should be extracted to prevent aspiration NEONATAL TOOTH  Tooth appearance within 28 days of life  Anodontia: (-) tooth up to 5 yrs ORAL THRUSH/ MONILIASIS • Caused by fungi Candida albicans • White cheese/curd-like patches at mouth and tongue • Obtained via NVD to mother with vaginal thrush • Management • Never remove it! May cause bleeding → septicemia • Wash mouth with cool boiled water • Apply Nystatin oral cream as ordered KAWASAKI DISEASE • Or Mucocutaneous Lymph Node Syndrome • Acute systemic vasculitis of unknown cause • Self-limited • Common among Asians (disease originated in Korea) • Complications: dilation of coronary arteries→ MI (S/Sx in children: abdominal pain, vomiting, restlessness, pallor, shock) and aneurysm, damage to heart muscle • Diagnostic Criteria (Acute Stage) • Fever > 5 days • Bilateral Conjunctivitis • Red throat • Swelling of cervical lymph node to > 1.5 cm in diameter • Swollen hands & feet • Polymorphous rash (primarily on trunk) • Subacute Stage • Changes of lips and oral cavity • dry, red fissure lips • STRAWBERRY TONGUE • Changes of peripheral extremities • Desquamation of the skin from tips of fingers and toes • Joint pain • Cardiac manifestations • Thrombocytosis • Convalescent Stage • Child appears normal but signs of inflammation may be present Three Phases • Acute: all S/Sx appears, + restlessness for 2 months (hallmark of KD) and arthritis • Subacute: resolution of all S/Sx, at greatest risk of coronary artery aneurysms (blood vessels stretch 4 wks post onset) and coronary thrombosis (due to thrombocytosis and hypercoagulability) • Convalescent: blood values return to N (6-8 wks post onset) e.g. ↓ ESR, ↓ thrombocytosis Management • Monitor • T frequently • Heart sounds & rhythm • Extremities for edema, redness & desquamation • Eyes & mucous membranes for inflammation • Dietary & fluid intake • Weight OD • Passive ROM exercises to facilitate joint movement • Give soft foods/liquids (not too hot or too cold) • Administer as ordered 50 aoih0718

Pedia

• • •

•

High dose IV Immunoglobulin during the 1st 10 days: 2g/kg as 10-12 hr drip (to ↓ incidence of coronary artery lesions & aneurysms) S/E: allergic rxn, extravasation, ↓ production of antibodies (delay MMR vaccine 11 mos. and chickenpox vaccine 5 mos after IVIG) Aspirin • High dose: 80-100mg/kg/day (in divided dose q6h) antipyretic and antiinflammatory (S/E toxicity: tinnitus, HA, dizziness, confusion) • Low dose: 3-5mg/kg/day antiplatelet (S/E easy bruising→ avoid contact sports) Warfarin (Coumadin) for children with giant aneurysm (>8 mm)

CLEFT LIP & CLEFT PALATE • Congenital anomaly • Failure of the soft tissue or bony structure to fuse during embryonic development • Causative factors • Genetic, Hereditary, Environmental, Radiation, Rubella virus, Teratogens CLEFT LIP • Failure of the median maxillary nasal processes to fuse by 5-8 wks of pregnancy • Can be unilateral or bilateral • Common in boys • Surgery: Cheiloplasty • done as early as 1-3 mos not to remove sucking reflex CLEFT PALATE  Failure of the palate to fuse  Common in girls  Surgery: Uraroplasty  done as early as 4-6 or 12-18 mos to allow normal palatal growth & not to impair speech Management  Emotional support  Nutritional support (prevent aspiration)  Use feeding devices  Post cheiloplasty: rubber tipped Asepto syringe with large hole  Post uraroplasty: paper cup, soup spoon, plastic cup  Nutritional support (prevent aspiration)  ESSR method of feeding  E-nlarge (crosscut) the nipple  S-timulate sucking  S-wallow  R-est  Feed in upright position  Direct thickened formula to the side & back of mouth  Small, frequent feeding  Prevent colic: Burp q 1oz of feeding  Encourage breast feeding if appropriate  Keep suction equipment & bulb syringe at bedside  Soft elbow or jacket restraints pre-op (so baby can adjust post-op); remove q2h to assess skin  Resched OR if with URTI  Post-op positioning  Cheiloplasty: side lying  Uraroplasty: prone  Maintain integrity of Logan bow (lip protector)  Prevent baby from crying  Cleanse it with half-strength H2O2 or pNSS  s/p Uraroplasty: oral packing for 2-3days, no tooth brushing, no hard foods (toasts, cookies)  AVOID  Sharp objects in mouth (oral suction, tongue depressor, thermometer, straw, spoon, fork, pacifier) NECK   

N: Short and thick, almost non-existent Trachea in midline Thyroid gland not palpable 51 aoih0718

Pedia  

Appears soft, chubby, creased with skin folds Good ROM and ability to flex & extend

CONGENITAL TORTICOLIS  Or Wry neck  Injured sternocleidomastoid muscle  Birth injury r/t excessive traction during cephalic delivery  Mgt: passive neck stretching exercises daily CONGENITAL CRETINISM  Or Thyroid Dysgenesis

 







CHEST     

Absence or non functioning thyroid glands Delayed diagnosis in NB because  Thyroid gland is covered by sternocleidomastoid  Baby received maternal thyroxine  Baby N sleeps 16-20 hrs/day Signs and Symptoms  Changes in sucking (poor)  Changes in crying (weak)  Sleeps excessively  Constipation  Edema (moon-face)  MR (late sign) Diagnostic Test  Protein bound I2  Radio immunoassay test  RAIU (RadioActive Iodine Reuptake) test Treatment  Thyroxine (Synthroid) for lifetime  S/E tachycardia (hyperthyroidism) NI! Check HR prior to giving of meds N: smaller than the head Circular: AP diameter = 1:1 Temporary breast engorgement with Witch’s milk (thin, watery fluid) r/t effect of maternal hormones Breathing: diaphragmatic and abdominal Clavicles intact

ABDOMEN: DIAPHRAGMATIC HERNIA  Most urgent of neonatal emergencies  Congenital malformation of diaphragm: Displacement of the abdominal organs into the thoracic cavity (usually on L)  Signs and Symptoms  Bowel sounds heard at chest  Shift of heart to side opposite the hernia

 

 

Large, asymmetric chest contour Dullness upon percussion on affected side ↓ breath sounds CXR: presence of intestines in thorax and mediastinal shift

GASTROINTESTINAL SYSTEM  Functions:  Assists in maintaining fluid and electrolyte and acid/base balance  Processes and absorbs nutrients to maintain metabolism and support growth and development  Excrete waste products from the digestive processes SUPPLEMENTAL FEEDING  Principles

52 aoih0718

Pedia

     

 

Solid food are offered according to the following sequence: cereals (given as early as 4 mos: start of iron catabolism, usually given at 6 mos: iron catabolism is complete)→fruits →vegies →meat →finger foods → table foods Begin with small amount Finger foods are offered by 6 mos Dilute citrus juices offered by 6 mos Offer new food one at a time, with interval of 4-7 days (to determine food allergy) Soft table food (modified family menu) offered by 12 mos (baby in high chair) Avoid giving half-cooked egg → Salmonellosis Avoid giving honey → Infant Botulism

FLUID AND ELECTROLYTE/ ACID-BASE BALANCE  Dependent on the following:  chemical buffers  renal and respiratory system involvement  dilution of strong acids and bases in blood ACID-BASE IMBALANCE  Respiratory acidosis  Hypoventilation conditions  Apnea  Cystic fibrosis (CO2/air trapping)  Respiratory alkalosis  Hyperventilation conditions  Tachypnea: asthma, RDS  Metabolic acidosis  Chronic diarrhea  Severe hypothermia: NB and infants  Metabolic alkalosis  Chronic vomiting  Prolonged suctioning of GI contents  GI post-op (bowel obstruction)  NGT NPO to suction to decompress stomach VOMITING  Forceful ejection of gastric contents thru the mouth  Usually self-limiting, no specific tx unless Cx occurs  Signs and Symptoms and Causes









Vom+T+ diarrhea= GI infection  Vom+constipation= GI obstruction Signs and Symptoms and Causes  Vom+localized abdominal pain= appendicitis, pancreatitis, peptic ulcer

 

Vom+↓LOC+HA= CNS or metabolic disorders



R-ice A-pplesauce

Projectile vom=pyloric stenosis, ICP  Others: toxic ingestion, food intolerance/allergy, psychogenic disorders Assessment of color and consistency  Green/bilous= bowel obstruction  Curdled, mucus or fatty foods several hrs post ingestion= poor gastric emptying or high intestinal obstruction Management: tx underlying cause  B-anana not given to pt with 



diarrhea; ↓ energy electrolytes and CHON

 T-oast CHO (osmolality) Nursing Management  Upright positioning during feeding to prevent aspiration  Oral care post vomiting  Liberal fluids with CHO to spare body protein and prevent ketosis 53 aoih0718

Pedia DIARRHEA

 



CNSD  

in stool frequency (>3-5x/day) with water content 2 Types  Acute diarrhea  CNSD (Chronic Non-Specific Diarrhea) Associated with  Gastroenteritis: bacteria, virus, fungi  Dietary causes: overfeeding, excess sugar in formula, intro of new foods  Meds: laxatives and antibiotics  Amox, Ampi, Pen  Poisoning: Arsenic, Lead, Mercury, Organophosphate Or Irritable Colon of Childhood or Toddler’s Diarrhea Associated with  Food (Lactose) intolerance

 

Excessive softdrinks/ fruit juices: sorbitol and fructose

↓ fat diet: restricted dairy and milk products *osmotically active, CHO, ↓ e+  Associated with contaminated water  2 wks duration, no S/Sx of malnutirition, enteric infection and dehydration

 rate of gastric emptying and intestinal transit time ASSESSMENT 

u.o., ↓ weight, (-) tears, (-) saliva, dry mucous membranes, poor skin turgor, sunken fontanel, pale cool dry skin

 Severe DHN: ↓BP, HR, RR, >2sec CRT (impending shock) COMPLICATIONS  1. Dehydration   

Mild: 5-6%, thirst, slighty dry buccal mucosa Moderate: 7-9%, (-) skin turgor, sunken eyes and fontanel Severe:>9%, S/ of moderate DHN + one of the following  Rapid, thready pulse





RR  Lethargy to coma  Severe metabolic acidosis 2. Electrolyte Imbalance





Metabolic acidosis (H+)  Respiratory alkalosis 3. Malnutrition

 Due to ↓ dietary intake, malabsorption syndrome and catabolic response to infection MANAGEMENT  Oral Rehydration Solution (ORS): Pedialyte, Hydrite, Infalyte, WHO), rice-based ORS as substitute  Tx of choice for mild to mod DHN 

 

Physiologic basis: glucose-mediated solution Na+ absorption  Most effective, less painful, less costly than IV  Replace stool losses with ½-1 cup ORS IV (plain LR or D5NSS) For severe DHN with shock: 20-30 cc/kg bolus



Anti-diarrheal meds (Lomotil, Imodium) not recommended: worsen diarrhea→toxicity and ADR due to ↓ motility, ileus may occur NURSING CARE  Assess hydration status, weigh OD, I/O, urine specific gravity  Continue breastfeeding and usual diet  Skin care on perianal area (Zinc oxide cream)  No rectal T!: stimulate bowel and stool passage  Hand washing, proper disposal of diapers 54 aoih0718

Pedia HIRSCHSPRUNG’S DISEASE  Or Congenital Megacolon or Aganglionosis

  





 

  

 

 





(-) of ganglion cells in rectum & upward colon (for peristalsis)→ mechanical obstruction Cx: Enterocolitis (fever, GI bleeding, explosive watery diarrhea) Assessment in Newborn  Failure to pass meconium within 24 hrs  Abdominal distention  Foul-odor of breath/vomitus of bile/fecal material Assessment in Children  Poor weight gain & delayed growth  Ribbon-like & Foul-smelling stool  Vomiting  Constipation alternating with diarrhea Diagnostic Tests  Barium Enema — reveals the narrowed portion of the bowel  Rectal Biopsy – (-) ganglion cells  Abdominal x-ray – reveals dilated loops on intestine  Rectal manometry – reveals failure of intestinal sphincter to relax Management Diet, stool softeners, daily rectal irrigation with pNSS  2-stage Surgery 1. Temporary colostomy

 Diet: CHON, calories, ↓ residue (can cause obstruction) 2. Trans-anal anastomosis and pull-through & closure of colostomy Pre-op Management Maintain NPO status Monitor  Bowel functions  Hydration & electrolyte status  Weight, I/O  Abdominal girth  RR distress Avoid taking rectal temp! Administer as ordered  IV fluids  Antibiotics  Bowel prep Post-op Management Maintain  NPO status until bowel sounds return (48-72hrs)  IV fluids until progressive oral intake is tolerated Assess  Stoma (should be pink & moist) for bleeding, skin breakdown, provide colostomy care  Surgical site for redness, swelling & drainage  Anal area for stool, redness, drainage Administer Analgesics, Antipyretics, Antibiotics as ordered

GASTROESOPHAGEAL REFLUX DISEASE (GERD)  Or Chalasia  Presence of stomach contents in esophagus due to relaxed/incompetent LES  Vs. Pyrosis (Heartburn): HCl contents go back to stomach  Assessment  Passive regurgitation  Hematemesis  Melena  Irritability  Failure to thrive/poor wt gain  Anemia from blood loss  Diagnostic Tests 55 aoih0718

Pedia  Barium Esophagogram – reveals reflux  Esophageal Manometry— reveals lower esophageal sphincter pressure  Intraesophageal pH content – reveals high pH of distal esophagus Complications  Esophagitis  Esophageal strictures  Aspiration pneumonia Management  Monitor  Amount & characteristics of emesis  Relationship of vomiting to times of feeding & child’s activity  Place suction equipment at bedside  I/O  S/Sx of dehydration  Maintain rehydration (IV, po)  Support nutrition (For infants: same as in cleft lip/palate)  For toddlers: feed solids 1st then liquids  Avoid fatty foods, chocolate, tomato products, carbonated drinks, fruit juices, citrus products & spicy foods  Avoid vigorous play after feeding  Avoid feeding just before bedtime  Pain meds for reflux pain (Acetaminophen)  Cholinergic Meds

 

Bethanecol – to esophageal tone and peristaltic activity Metochlopramide (Regnan/Plasil)- to ↓ esophageal pressure by relaxing pyloric and duodenal segments, peristalsis without stimulating secretions





H2 blocker- to ↓ gastric acidity and pepsin secretion  Antacids (Maalox)- to neutralize gastric acid between feedings Surgery: Nissen Fundoplication  Creation of valve mechanism by wrapping the greater curvature of stomach  To create pressure and prevent backflow to esophagus (to restore competence of LES)

PYLORIC STENOSIS



Hypertrophy of circular muscles of pylorus → narrowing & obstruction Signs and Symptoms  Projectile vomiting after feeding  Vomitus: gastric contents, with mucus or blood, no bile  Hunger, irritability  Olive-shaped mass at RUQ  Peristaltic waves visible from left to right across epigastrium during or after feeding  Metabolic alkalosis, electrolyte imbalance  Dehydration, malnutrition Diagnostic Tests  ABG: metabolic alkalosis





Serum electrolyte: Na and K, ↓ chloride  Ultrasound: confirms diagnosis  X-ray of upper abdomen with barium swallow (reveals tinged sign) Management  Pyloromyotomy (incision through the muscle of pylorus, done under laparoscopy)

INTUSUSSCEPTION  Telescoping or invagination of one part of the bowel to another portion

 

Most common site: ileoceccal junction → inflammation → necrosis → PERITONITIS (ER of GIT; persistent abdominal pain) → perforation & shock Assessment  Currant-jelly stools (due to inflammation and bleeding)  Palpable sausage-shaped mass at RUQ  Abdominal distention & pain  Bile-stained fecal vomitus 56 aoih0718

Pedia 

 Lower GI series (Barium enema): staircase or coiled spring sign Management  Hydrostatic reduction with Barium enema  WOF passage of barium & normal brown stool  Anastomosis and pull-through

ABDOMINAL DEFECTS: OMPHALOCELE  Hernia of umbilical cord, with intact peritoneal sac

  

Rupture of sac→ evisceration of abdominal contents Cover sac with sterile gauze soaked with pNSS then with plastic wrap to prevent drying Maintain on NPO, IV fluids/TPN, prevent hypothermia & infection

GASTROSCHISIS  Hernia of intestine lateral to the umbilical ring, no membrane covers the exposed bowel  Cover exposed bowel with LOOSE sterile gauze soaked with pNSS then with plastic wrap to prevent drying, pressure & necrosis  Emergency surgical repair needed  Maintain on NPO, IV fluids/TPN, prevent hypothermia & infection INBORN ERRORS OF METABOLISM: PHENYLKETONURIA  Inborn error of CHON metabolism  Autosomal recessive disorder  Deficient in liver enzyme Phenylalanine Hydroxylase Transferase (PHT) needed for the conversion of phenylalanine to thyrosine (needed for melanin production)  Signs and Symptoms  Fair skin  Blonde hair  Blue eyes  Infantile eczema/atopic dermatitis  Musty odor urine  CNS affectation: Hyperactivity, seizure, MR *all due to accumulation of phenyl pyruvic acid (from unconverted phenylalanine)  Diagnostic Tests  Blood phenylalanine >8mg/dL (N: <2mg/dL 2-5days after birth)  Guthrie Bacterial-inhibition Test  Specimen: urine

 Preparation: CHON intake, 3-4 days post breast feeding (to allow phenylalanine build-up) Phenistix Test  Specimen: urine + Ferric Chloride  (+) greenish spots at diaper Management: avoid neurologic damage 



  

↓ Phenylalanine diet indefinitely No meat, legumes (peanuts), dairy products & aspartame Take Lofenalac milk formula (synthetic AA)

GALACTOSEMIA  Inborn error of CHO metabolism  Deficient Galactose-1 Phosphate Uridine Transferase needed for conversion of galactose to glucose  Damages liver, spleen, brain and eyes (cataract)  Assessment





NB appears to be N at birth but after milk ingestion ( lactose) vomit →lose weight → malnourished  Death during 1st mo of life occurs if infant is untreated Management  Eliminate all milk and lactose-containing foods (even breast milk)  Use lactose-free formula (Soy protein formula)  Gene replacement therapy (very expensive)

57 aoih0718

Pedia NEWBORN SCREENING TEST -should be performed before any blood transfusion and after sufficient protein intake -NB should be on formula or breast milk for 24 hrs before screening APPENDICITIS  Inflammation of appendix



Perforation may occur in a matter of hours→ peritonitis & sepsis  Treatment: appendectomy before perforation occurs Signs and Symtpoms  Pain: periumbilical area descends to RLQ, most intense at McBurney’s point  Rebound tenderness & abdominal rigidity

   

WBC, low grade fever A/N/V, diarrhea Side-lying position with abdominal guarding (legs flexed) Sudden relief of pain then becomes intense



fever, HR, RR  Progressive abdominal distention  Pallor, chills  Restlessness, irritability Pre-op Management  Maintain NPO  Promote comfort  R sidelying or semi-Fowler’s position  Abdominal ice packs q 20-30mins hourly  Monitor  Changes in pain level  Bowel sounds  Avoid  Heat application  Rectal exam, thermometer, enema, laxatives  Administer as ordered  IV fluids  Antibiotics Post-op Management  Maintain NPO, maintain NGT suction  R sidelying or semi-Fowler’s position to keep Penrose drain patent  Monitor for





T, redness, swelling pain at site (infection)  Presence of bowel sounds (to start feeding) Administer as ordered  Antibiotics  Analgesics

POISONING  Common among toddlers  Principles  Determine the substance taken  Unless the poison was corrosive, caustic (strong alkali such as LYE) or a hydrocarbon, vomiting is the most effective way to remove the poison from the body Principles Syrup of Ipecac- oral emetic to cause vomiting after drug over dose or poisoning  15 ml to adolescent, school age and pre-school  10 ml to infant  Can give up to 2nd dose if don’t vomit after 1st dose  Universal antidote - charcoal, milk of magnesia, and burned toast Never administer the charcoal before ipecac Antidote for Acetaminophen poisoning: Acetylsysteine (Mucomyst) to prevent liver damage  For caustic poisoning:  

 

58 aoih0718

Pedia

 

 



 



 Give vinegar (low % acidity) to neutralize strong acids (HCl)  Give mineral oil to coat intestines during gasoline ingestion  Prepare tracheostomy set (in case of airway stricture) Sources: paint, varnish, battery, crayons, pencil, smoke-belching vehicles Via ingestion or inhalation 1st interferes RBC functioning →hypochromic, microcytic anemia → destroying bones, teeth, kidneys → accumulation of NH4 → encephalopathy (affects CNS) Assessment  beginning symptoms of lethargy  impulsiveness and learning difficulty  as lead increases, severe encephalopathy with seizures and permanent MR Diagnostic Tests  Blood Smear: >20mcg/dL: acute poisoning  Erythrocyte protoporphyrin test (indicates anemia) N: <35mcg/100ml blood  Abdominal X-ray  Long Bones Chelation therapy: removes lead from blood/organ/tissues Meds:  Calcium disodium edetate (EDTA) po: for > 20 mcg/dl lead in blood  Dimercaprol (BAL in oil): not given if with allergy to peanuts  Succimer (Chemet) All meds S/E: nephrotoxicity  Force fluids  WOF BUN, Creatinine levels

ACETAMAINOPHEN POISONING  Toxic dose: >150mg/kg  Signs & Symptoms  1st 2-4hrs: malaise, N/V, sweating, pallor, weakness  Latent period 24-36hrs: child improves





Hepatic involvement: up to 7days & may be permanent; RUQ pain, jaundice, confusion, stupor, liver enzymes, bilirubin, Pro time Management: N-Acetylcysteine (Antidote)  Dilute in juice/soda to remove offensive odor

ASPIRIN POISONING  Toxic dose: Acute ingestion: 300-500mg/kg  Chronic ingestion:>100mg/kg/day X2days or more  Signs & Symptoms



   

N/V, thirst, hypoglycemia, ↓Na+, ↓K+, diaphoresis, oliguria, bleeding, dehydration, fever  Hyperpnea, confusion, tinnitus, seizure, coma, respiratory & circulatory failure Management Syrup of Ipecac, gastric lavage with activated charcoal Administer as ordered: IVF, NaHCO3, electrolytes, volume expander, glucose, Vit. K Prepare for dialysis if unresponsive to the therapy

ANOGENITAL AREA  Both sexes: foul-smelling urine (Urethroanal fistula)  Female  N in NB:  Labia edematous, clitoris enlarged  Pseudomenstruation  Hymen tag may be visible  1st voiding within 24 hrs  N in adolescents: inverted triangle shape of pubic hair  Preschool: thinning of fourchet (rape/child abuse)  Bruises: identical (e.g. cigarette butts), of different stages  Report within 48 hrs  Keep child in safe environment 59 aoih0718

Pedia  

Male   

 

No erasure in nurse’s notes (used as evidence)

N: Prepuce (foreskin) covers glans penis, with milky covering (should not be disrupted) Scrotum edematous 1st voiding within 24 hrs Sperm cells need <2°C from body T for spermatogenesis Testicles descend immediately after birth or within 24hrs; otherwise- Cryptorchidism (common among preterms; N descend by 28-32 wks AOG up to 12 mos.)  During assessment: warm hands and room



    



 

Meds: HCG: testosterone production  Surgery: Orchiopexy with Torek procedure at 1-2 yrs of age Hydrocele- abdominal fluid in scrotum  (+) Transillumination test Varicocele- enlarged vein of epididymis N Voiding within 24hrs, otherwise renal agenesis Epispadias- dorsal urinary meatus or above glans penis Hypospadias- ventral urinary meatus or below glans penis  Not circumcised (foreskin used in surgical repair)  Surgery at 16-18 mos. age before toilet training  Post-op: Force fluids, keep urinary stent patent, WOF (-) u.o. (possible kink), no tub bathing until stent is removed Chordee- penis curve downward due to fibrous band  N retraction of prepuce at 6 wks Phimosis- very tight, unretractable prepuce (foreskin)→ accumulation of smegma→ infection of glans penis (Balanitis) N in adolescents: diamond-shape pubic hair

RENAL DISORDER: NEPHROTIC SYNDROME Cause Assessment Findings Infectious Hypoalbuminemia, anasarca, massive proteinuria, microscopic or (-) hematuria,↓ serum CHON, serum lipid, N or ↓ BP AGN Cause Non-infectious Auto-immune Group A Beta Strep throat 23 wks before Sx Hx: impetigo

Assessment Findings Primary edema, Peripheral edema, Periorbital edema in am, ↓ u.o., mod. Proteinuria, gross hematuria (smoky urine, Cx: anemia), fatigue, serum K+, − BUN Crea, ASO titer, BP

Treatment Corticosteroid (Prednisone) Immuno-suppresant Diuretics Plasma expander (salt-poor human albumin)

Nursing Care Monitor VS, I/O, urine SG, albumin, edema Weigh OD (same time, clothing, scale) Assess for DHN Diet: CHON, ↓ Na+ WOF infection

Treatment Antihyper-tensives Hydralazine (Apresoline) Diuretic Antibiotics Fe infusion

Nursing Care Monitor BP, neuro status, wt, I/O, seizures Diet: ↓ Na+, ↓ K+, ↓CHON in severe azotemia, Fe WOF Cx: Hypertensive Encephalopathy, RF, pulm. edema, HF

BACK  N: on prone appears flat, curves start to form when child has learned how to sit or stand  Spine straight SPINA BIFIDA  CNS defect as a result of neural tube defect during embryonic development  Associated deficits:  Sensory motor disturbance  Hip dislocation  Clubfoot  Hydrocephalus SPINA OCCULTA  Congenital malformation of the spine  Posterior portion of the vertebrae fails to close 60 aoih0718

Pedia  No herniation of meninges thru the defect  Neuro deficits usually absent SPINA BIFIDA CYSTICA  With herniation of meninges thru the defect  3 Types  Meningocele: herniation of meninges, contains CSF but not CNS tissue  Myelomeningocele- with CSF and CNS tissue (cord, nerve root); neuro deficits present Prenatal Diagnostic Tests  Alpha fetoprotein: maternal blood and amniotic fluid determination  Ultrasound  Amniography Common Complications  Hydrocephalus  Permanent impairment of neuromuscular function below level of defect  paralysis, flaccid or spastic muscles  Poor sphincter control (assess for character and number of voiding and stools)  CSF infection Management  Evaluate the sac; measure the lesion

     



WOF hydrocephalus, ICP; measure HC, check fontanels for fullness Prone or sidelying with rolled towel to prevent pressure/injury to the defect Cover sac with sterile, moist (normal saline), non-adherent dressing; change dressing q2-4hrs and when soiled Skin care: dressings, ointments as ordered Prevent infection of the sac Administer meds as ordered:  Antibiotics: to prevent infection  Anticholinergics: to improve urinary continence  Antispasmodics: to control bladder spasms  Laxatives: to improve bowel continence Treatment: Surgical repair during infancy

SCOLIOSIS • Lateral curvature of the spine • Most common during the growth spurt, early adolescent stage • F>M Assessment • visible curve fails to straighten when the child bends forward and hangs arms down toward feet (Adam’s position) • Asymmetrical shoulder height, scapula and flank shape • rib prominence and rib humps • Screening begins at 8 yrs Management • Milwaukee Brace- worn between 16-23 hrs/day – Not curative, but preventive: Slows/Halts progression of the curvature when child reaches skeletal maturity – Inspect the skin for signs of redness or breakdown – Keep the skin clean and dry, avoid lotions and powders – Advise the child to wear soft, nonirritating clothing under the brace • Supplemental exercises: to prevent atrophy of spinal and abdominal muscles • Support in coping: Adolescents may modify lifestyle, may feel stigmatized from peers by being “different” • Surgery: Internal Fixation and Instrumentation combined with Spinal arthrodesis (fusion) • Logroll when turning, to maintain alignment post-op • Assess extremities for neurovascular status • Promote coughing & DBE, incentive spirometry • Give pain meds as ordered • WOF vomiting, abdominal distention: Superior Mesenteric Artery syndrome r/t mechanical changes in position of abdominal contents during surgery • Prepare child in using molded plastic jacket during activity EXTREMITIES • N in state of flexion 61 aoih0718

Pedia • • • • • • • • • • • • •

Full ROM, symmetrical movements Palms and soles with numerous creases Arms and legs appear short Hands are plump, clenched into fists 10 fingers, 10 toes, all separate Legs bowed Slight tremors common but can be a sign of hypoglycemia or drug withdrawal Digits Syndactyly – webbing of digits Polydactyly – extra digit Olidactyly – lack of digit *Amelia – total absence of extremities *Pocomelia – absence of distal part of extremities (both * due to effect of Thalidomide)

BRACHIAL PALSY (ERB DUCHENE’S PARALYSIS) • Brachial plexus injury due to excessive lateral traction during breech delivery Signs and Symptoms • (-) or asymmetric Moro reflex • Inability to: • Abduct arm from shoulder, • Rotate arm externally • Supinate forearm • Management • Abduct arm from shoulder with elbow flexed CONGENITAL HIP DYSPLASIA • condition in which the head of the femur is improperly seated in the acetabulum, or hip socket, of the pelvis • 2 Types – Subluxated (half dislocation, more common) – Dislocated (total dislocation) Assessment • Shortening of the affected leg • Asymmetrical gluteal fold • Limited ROM • (+) Barlow or Ortolani’s sign The walking child • The child limps; minimal to pronounced variation in gait with lurching toward the affected side; (+) Trendelenburg sign (late sign) Management • Goal: facilitate hip abduction & external rotation • Double or Triple the diaper • Carry the baby in stride • Frejka (abduction) Splint • Pavlik harness (neonatal period) • Hip Spica Cast • Traction or surgery TALIPES • Or Club Foot; congenital malformation of LE, uni- or bilateral; defect is rigid & cannot be manipulated into a neutral position • Types • Equinos – Plantar flexion or Horsefoot • Calcaneous or Dorsiflexion – the heel is held lower than the foot/the anterior portion of foot is flexed towards the anterior leg • Varus – foot turns in • Valgus – foot turns out • Management • Treatment begins as soon after birth • Serial manipulation & casting weekly for 3-6 months, otherwise surgery • Cast care FRACTURE 62 aoih0718

Pedia Break in the continuity of the bone due to trauma, twisting or bone decalcification • In children: r/t mobility, immature motor & cognitive skills • In infants: rare, r/o child abuse Signs and Symptoms • Pain or tenderness on affected area • Loss of function • Obvious deformity • Ecchymosis • Edema • Muscle spasm Management • Assess extent of injury, immobilize affected extremity • In compound fracture, splint extremity, cover wound with sterile dressing • Reduction: restoring bone to proper alignment • Closed: manual alignment followed by immobilization • Open: surgical insertion of internal fixator (rods, wires, pins) • Use of cast & traction •

CAST •

Function: – For immobilization – Maintains bone alignment – Prevents muscle spasm • Materials – Gypsum (CaSO4 crystals) – Stockinette: prevents irritation – Lead pencil: to mark area – Basin of water • Warm: slows setting process • Cold: hastens setting process Nursing Care • Priority: Neurovascular Check – C-irculation – M-otion – S-ensation • WOF S/Sx Impaired Circulation (Mgt: bivalving) – B-lueness/ Coldness – L-ack of distal peripheral pulse – E-dema not corrected by elevation – P-ain on casted extremity – T-ingling sensation (refer asap!) • Use open palm to prevent indentation • Support cast with soft pillow • May use blower: low, cool setting to dry • Mark area with bleeding with a pen • Don’t put anything inside the cast

CRUTCHES • Purpose – For support – To maintain balance • Use the palms: prior to use- do palm exercises using squeeze ball (to strengthen hand grip) • The distance between the axilla and the arm piece on the crutches should be at least 3 fingerwidths below the axilla • The elbows should be slightly flexed, 30 degrees • When ambulating with the client, stand on the affected side • Crutch stance: tripod (triangle) position (6-10 inches in front and to the side) • Never to rest the axilla on the axillary bars • Look up and outward when ambulating • Stop ambulation if numbness or tingling in the hands or arms occurs CRUTCH GAITS • Swing through and Swing to: if weight-bearing is not allowed in 2 LE • 3-point gait: if weight-bearing is allowed in 1 LE 63 aoih0718

Pedia •

2-point and 4-point gait: if weight-bearing is allowed in 2 LE

TRACTION  mechanism by which a steady pull is placed on a part or parts of the body  Used to reduce dislocation and immobilize fractures PRINCIPLES OF TRACTION  The client should be in dorsal or supine position  For every traction there is always a counter traction.  Line of pull should be in line with deformity



For traction to be effective it must continuous

2 TYPES OF TRACTION Skin traction  Application of wide band of moleskin, adhesive, or commercially available devices directly to the skin and attaching weights to them 1. Buck’s extension • Exerts straight pull on the affected extremity; to immobilize the leg in patient with a fractured hip • Has a horizontal weight • Turn towards unaffected side • Check for pressure sore at the heel of the foot* 2. Russell traction • Knee is suspended in a sling attached to a rope and pulley on a Balkan frame, creating upward (double)pull from the knee • Weights are attached to the foot of the bed • Used to treat fracture of the femur • Allows patient to move about in bed more freely and permits bending of the knee joint • Assess back of the knee for pressure sores 3. Bryant’s traction • Both legs raised 90 angle to bed • Used for children under 3 years and 30 lbs to treat fractures of the femur and hip dislocation • Buttocks must be slightly off mattress • Knees slightly flexed 3. Pelvic traction – Pelvic girdle with extension straps attached to ropes and weights – used for low back to reduce muscle spasm and maintain alignment Skeletal Traction • Traction applied directly to the bones using pins, wires, or tongs (Crutchfield) that are surgically inserted, used for fractures femur, tibia, humerus, cervical spine 1. Balanced Suspension Traction • Produced by a counterforce other than the patient’s weight • Extremity floats or balances in the traction apparatus • Patient may change position without disturbing the line of traction • Used for displaced or overriding fx of femur • Relieves muscle spasms • Realigns fx fragments • Promotes callus formation COMMUNICABLE DISEASES MEASLES (RUBEOLA)  Agent: Paramyxovirus  Incubation period: 10-20 days  Communicable period: 4days before to 5days after rash appears  Source: respiratory tract secretions, blood, urine  MOT: airborne, direct contact with droplets Signs and Symptoms  Fever, malaise, cough  Stimson’s eye (conjunctivitis), puffy eyelids, mucopurulent d/c, photophobia  Stomatitis  Maculopapular rash begins at behind ears spreads down to feet, dries & peels off 64 aoih0718

Pedia  Koplik spots: small, red spots with bluish white center at oral mucosa X3days Management  Respiratory isolation, Bed rest  Cool mist vaporizer for cough  Eye care, Dim lights for photophobia  Ear care, WOF otitis media  Oral care, Nystatin (antifungal) swish & swallow  Skin care, Calamine lotion (Caladryl)  TSB, Antipyretics for fever  Vit A 200,000 IU (<6y/o) to maintain healthy eyes, skin, prevent pneumonia & diarrhea GERMAN MEASLES (RUBELLA)  Agent: Togavirus  Incubation period: 14-21 days  Communicable period: 7days before to 5days after rash appears  Source: respiratory tract secretions, blood, stool, urine  MOT: airborne, direct contact with droplets, transplacental Signs and Symptoms  Low grade fever, malaise  Pinkish red maculopapular rash begins at face spreads to entire body  Forscheimer’s spots: petechial spots at soft palate Management  Respiratory isolation away from pregnant within 1st trim. (teratogenic & abortive)  Bed rest  Supportive treatment  Vaccine (SQ) Contraindications  Allergy to neomycin & related antibiotics  Pregnancy (N titer: 1:8-10)  Immunodeficiency  IVIg & BT (vaccine postponed for 3 mos) MUMPS  Agent: Paramyxovirus  Incubation period: 14-21 days  Communicable period: immediately before & after swelling begins  Source: saliva, urine  MOT: direct contact with droplets Signs and Symptoms  Fever, HA, malaise  Anorexia  Earache esp. when chewing  Parotid gland swelling  Orchitis Management  Respiratory isolation, bedrest  Avoid food that require chewing  Hot or cold compress at neck  To relieve orchitis, apply warmth & local support with tight-fitting underpants CHICKENPOX (VARICELLA)  Agent: Varicella-zoster virus  Incubation period: 13-17 days  Communicable period: 1-2days before & up to 6days after crusting begins  Source: respiratory tract secretions, skin lesions  MOT: direct contact with droplets Signs and Symptoms  Low grade fever, malaise  Maculopustular rash becoming crusts, begins on trunk and scalp and spreads to extremities Management  Contact and Airborne isolation  At home, isolate child until vesicles have dried 65 aoih0718

Pedia 

Supportive care

PERTUSSIS (WHOOPING COUGH)  Agent: Bordetella pertussis  Incubation period: 5-21 days (usually 10 days)  Communicable period: during catarrhal stage  Source: respiratory tract secretions  MOT: direct contact with droplets Signs and Symptoms  Respiratory infection followed by severity of cough Management  Respiratory isolation  Avoid dust, smoke & sudden change in T  Encourage fluid intake  Administer as ordered  O2 tent with high humidity  Antibiotics  Pertussis Ig DIPHTHERIA  Agent: Corynebacterium diphtheriae  Incubation period: 2-5 days  Communicable period: after 3 (-) cultures, usually 2-4 weeks  Source: nasopharyngeal secretions  MOT: direct contact Signs and Symptoms  Low grade fever, malaise, sore throat  Foul-smelling, mucopurulent nasal d/c  Gray membrane on tonsils & pharynx  Lymphadenitis (neck edema) Management  Contact isolation  Bed rest  Administer as ordered  Antibiotics  Antitoxin after skin test to r/o sensitivity to horse serum TETANUS (LOCKJAW/TRISMUS)  Agent: Clostridium tetani (anaerobic, non-motile, spore forming)  Vegetative, active form releases  Tetanolysin- RBC hemolysis  Tetanospasmin- tonic type of seizures  Source: soil, gut of herbivorous animals  MOT: direct contact  Newborn: via umbilical cord  Children: via dental caries  Adult: via wound Signs and Symptoms  Lockjaw  Risus sardonicus (Sardonic smile/grin)  Opisthotonos  Intermittent muscular spasms with stimulation  Boardlike abdomen  Extension of extremities  Diaphoresis  Low-grade fever Management  Prevent spasm stimulation (note duration & freq.)  Exteroceptive: noise (ear plugs)  Proprioceptive: touch (no IM, TSB, no restraints, minimal handling)  Interoceptive: phlegm expectoration 66 aoih0718

Pedia  

 Light (dark room, eye shield) Suction secretions, padded tongue depressor Administer as ordered  O2, IV fluids while on NPO  ATS/TAT: to neutralize toxin after (-) skin test  Tetanus Ig- IM no need for skin test  Pen G, Metronizadole  Diazepam

POLIOMYELITIS  Agent: enteroviruses  Incubation period: 7-14 days  Communicable period: shortly after infection, 1 week in throat, 4-6 weeks in the feces  Source: oropharyngeal secretions & feces  MOT: direct contact, fecal-oral route Signs and Symptoms  Fever, malaise, A/N, HA, sore throat  Abdominal pain  Soreness, stiffness of trunk, neck & limbs  Flaccid paralysis Management  Enteric precautions, bed rest  Supportive treatment  WOF respiratory paralysis  Physical therapy IMMUNE SYSTEM: TYPES OF IMMUNITY TYPES OF IMMUNITY NATURAL ACTIVE Exposed and contract disease (longer to come, longer to go) and body produce own memory cells Received maternal Ab from placenta or breast milk

ARTIFICIAL Received vaccines and body produce own memory cells Received anti-serum with Ab preformed from another host

GENERAL CONTRAINDICATIONS: IMMUNIZATION  Moderate to severe illness with or without fever  Anaphylactic reaction to vaccine or substance in vaccine  Live virus vaccines not given to immunocompromised  HepB: IM, vastus lateralis (NB), deltoid (children)  CI: allergy to baker’s yeast  DTaP IM CI: encephalopathy within 7 days of vaccination  Hib: IM protection against bacterial meningitis & pneumonia, epiglottitis, septic arthritis, sepsis  IPV CI: allergy to neomycin or streptomycin

67 aoih0718

Pedia

Medical- Surgical Nursing Question/Answer/Rationale

Set 01 1. Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after surgery, the nurse should expect the use of: a. Diuretics b. Antihypertensive c. Steroids d. Anticonvulsants C. Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema. 2. Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should: a. Increase the flow of normal saline b. Assess the pain further c. Notify the blood bank d. Obtain vital signs A. The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume. 3. Nurse Maureen knows that the positive diagnosis for HIV infection is made based on which of the following: a. A history of high risk sexual behaviors. b. Positive ELISA and western blot tests c. Identification of an associated opportunistic infection 68 aoih0718

Pedia d. Evidence of extreme weight loss and high fever .

B. These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus (HIV).

4. Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an adequate amount of highbiologic-value protein when the food the client selected from the menu was: a. Raw carrots b. Apple juice c. Whole wheat bread d. Cottage cheese .

D. One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life.

5. Kenneth who has diagnosed with uremic syndrome has the potential to develop complications. Which among the following complications should the nurse anticipates: a. Flapping hand tremors b. An elevated hematocrit level c. Hypotension d. Hypokalemia .

A. Elevation of uremic waste products causes irritation of the nerves, resulting in flapping hand tremors.

6. A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be: a. Flank pain radiating in the groin b. Distention of the lower abdomen c. Perineal edema d. Urethral discharge B. This indicates that the bladder is distended with urine, therefore palpable. 7. A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and painful. The nurse should: a. Assist the client with sitz bath b. Apply war soaks in the scrotum c. Elevate the scrotum using a soft support d. Prepare for a possible incision and drainage. C. Elevation increases lymphatic drainage, reducing edema and pain. 8. Nurse hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? 69 aoih0718

Pedia a. Liver disease b. Myocardial damage c. Hypertension d. Cancer . B. Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred. 9. Nurse Maureen would expect the a client with mitral stenosis would demonstrate symptoms associated with congestion in the: a. Right atrium b. Superior vena cava c. Aorta d. Pulmonary D. When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent back ward flow into the pulmonary vein, the pulmonary circulation is under pressure. 10. A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be: a. Ineffective health maintenance b. Impaired skin integrity c. Deficient fluid volume d. Pain A. Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat. 11. Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including: a. high blood pressure b. stomach cramps c. headache d. shortness of breath C. Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension and dizziness. 12. The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD? a. High levels of low density lipid (LDL) cholesterol b. High levels of high density lipid (HDL) cholesterol c. Low concentration triglycerides d. Low levels of LDL cholesterol. 70 aoih0718

Pedia . A. An increased in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels. 13. Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm? a. Potential wound infection b. Potential ineffective coping c. Potential electrolyte balance d. Potential alteration in renal perfusion D. There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery. 14. Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12? a. dairy products b. vegetables c. Grains d. Broccoli A. Good source of vitamin B12 are dairy products and meats. 15. Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions? a. Bowel function b. Peripheral sensation c. Bleeding tendencies d. Intake and out put C. Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies. 16. Lydia is scheduled for elective splenectomy. Before the clients goes to surgery, the nurse in charge final assessment would be: a. signed consent b. vital signs c. name band d. empty bladder B. An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for. 17. What is the peak age range in acquiring acute lymphocytic leukemia (ALL)? a. 4 to 12 years. 71 aoih0718

Pedia b. 20 to 30 years c. 40 to 50 years d. 60 60 70 years A. The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age. 18. Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical manifestations may indicate all of the following except a. effects of radiation b. chemotherapy side effects c. meningeal irritation d. gastric distension . D. Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous system, and clients experience headaches and vomiting from meningeal irritation. 19. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is contraindicated with the client? a. Administering Heparin b. Administering Coumadin c. Treating the underlying cause d. Replacing depleted blood products B. Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin. 20. Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate? a. Urine output greater than 30ml/hr b. Respiratory rate of 21 breaths/minute c. Diastolic blood pressure greater than 90 mmhg d. Systolic blood pressure greater than 110 mmhg . A. Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 30 to 35 mL/hr. 21. Which of the following signs and symptoms would Nurse Maureen include in teaching plan as an early manifestation of laryngeal cancer? a. Stomatitis b. Airway obstruction c. Hoarseness d. Dysphagia 72 aoih0718

Pedia . C. Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be evaluated because it is one of the most common warning signs. 22. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it: a. Promotes the removal of antibodies that impair the transmission of impulses b. Stimulates the production of acetylcholine at the neuromuscular junction. c. Decreases the production of autoantibodies that attack the acetylcholine receptors. d. Inhibits the breakdown of acetylcholine at the neuromuscular junction. . C. Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction. 23. A female client is receiving IV Mannitol. An assessment specific to safe administration of the said drug is: a. Vital signs q4h b. Weighing daily c. Urine output hourly d. Level of consciousness q4h C. The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the kidney. 24. Patricia a 20 year old college student with diabetes mellitus requests additional information about the advantages of using a pen like insulin delivery devices. The nurse explains that the advantages of these devices over syringes includes: a. Accurate dose delivery b. Shorter injection time c. Lower cost with reusable insulin cartridges d. Use of smaller gauge needle. A. These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly. 25. A male client’s left tibia was fractured in an automobile accident, and a cast is applied. To assess for damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for: a. Swelling of the left thigh b. Increased skin temperature of the foot c. Prolonged reperfusion of the toes after blanching d. Increased blood pressure . C. Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack of blood supply to the extremity. 26. After a long leg cast is removed, the male client should: 73 aoih0718

Pedia a. Cleanse the leg by scrubbing with a brisk motion b. Put leg through full range of motion twice daily c. Report any discomfort or stiffness to the physician d. Elevate the leg when sitting for long periods of time. D. Elevation will help control the edema that usually occurs 27. While performing a physical assessment of a male client with gout of the great toe, Nurse Vivian should assess for additional tophi (urate deposits) on the: a. Buttocks b. Ears c. Face d. Abdomen B. Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow is least active, including cartilaginous tissue such as the ears. 28. Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the: a. Palms of the hands and axillary regions b. Palms of the hand c. Axillary regions d. Feet, which are set apart B. The palms should bear the client’s weight to avoid damage to the nerves in the axilla. 29. Mang Jose with rheumatoid arthritis states, “the only time I am without pain is when I lie in bed perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose should encourage: a. Active joint flexion and extension b. Continued immobility until pain subsides c. Range of motion exercises twice daily d. Flexion exercises three times daily . A. Active exercises, alternating extension, flexion, abduction, and adduction, mobilize exudates in the joints relieves stiffness and pain. 30. A male client has undergone spinal surgery, the nurse should: a. Observe the client’s bowel movement and voiding patterns b. Log-roll the client to prone position c. Assess the client’s feet for sensation and circulation 74 aoih0718

Pedia d. Encourage client to drink plenty of fluids . C. Alteration in sensation and circulation indicates damage to the spinal cord, if these occurs notify physician immediately. 31. Marina with acute renal failure moves into the diuretic phase after one week of therapy. During this phase the client must be assessed for signs of developing: a. Hypovolemia b. renal failure c. metabolic acidosis d. hyperkalemia . A. In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be replaced. 32. Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)? a. Protein b. Specific gravity c. Glucose d. Microorganism . C. The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to determine whether a body fluid is a mucus or a CSF. A CSF normally contains glucose. 33. A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, “What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the 20 years? a. Electrolyte imbalance b. Head trauma c. Epilepsy d. Congenital defect . B. Trauma is one of the primary cause of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease. 34. What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA? a. Pupil size and papillary response b. cholesterol level c. Echocardiogram d. Bowel sounds . A. It is crucial to monitor the pupil size and papillary response to indicate changes around the cranial nerves. 75 aoih0718

Pedia 35. Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Which of the following instruction is most appropriate? a. “Practice using the mechanical aids that you will need when future disabilities arise”. b. “Follow good health habits to change the course of the disease”. c. “Keep active, use stress reduction strategies, and avoid fatigue. d. “You will need to accept the necessity for a quiet and inactive lifestyle”. . C. The nurse most positive approach is to encourage the client with multiple sclerosis to stay active, use stress reduction techniques and avoid fatigue because it is important to support the immune system while remaining active. 36. The nurse is aware the early indicator of hypoxia in the unconscious client is: a. Cyanosis b. Increased respirations c. Hypertension d. Restlessness . D. Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in unconscious client who suddenly becomes restless. 37. A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which of the following? a. Normal b. Atonic c. Spastic d. Uncontrolled B. In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is catheterized. 38. Which of the following stage the carcinogen is irreversible? a. Progression stage b. Initiation stage c. Regression stage d. Promotion stage . A. Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing tumor that cannot be reversed. 39. Among the following components thorough pain assessment, which is the most significant? a. Effect b. Cause c. Causing factors 76 aoih0718

Pedia d. Intensity D. Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment. 40. A 65 year old female is experiencing flare up of pruritus. Which of the client’s action could aggravate the cause of flare ups? a. Sleeping in cool and humidified environment b. Daily baths with fragrant soap c. Using clothes made from 100% cotton d. Increasing fluid intake B. The use of fragrant soap is very drying to skin hence causing the pruritus. 41. Atropine sulfate (Atropine) is contraindicated in all but one of the following client? a. A client with high blood b. A client with bowel obstruction c. A client with glaucoma d. A client with U.T.I C. Atropine sulfate is contraindicated with glaucoma patients because it increases intraocular pressure. 42. Among the following clients, which among them is high risk for potential hazards from the surgical experience? a. 67-year-old client b. 49-year-old client c. 33-year-old client d. 15-year-old clien A. A 67 year old client is greater risk because the older adult client is more likely to have a less-effective immune system. 43. Nurse Jon assesses vital signs on a client undergone epidural anesthesia. Which of the following would the nurse assess next? a. Headache b. Bladder distension c. Dizziness d. Ability to move legs . B. The last area to return sensation is in the perineal area, and the nurse in charge should monitor the client for distended bladder. 44. Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Meniere’s disease except: a. Antiemetics 77 aoih0718

Pedia b. Diuretics c. Antihistamines d. Glucocorticoids D. Glucocorticoids play no significant role in disease treatment. 45. Which of the following complications associated with tracheostomy tube? a. Increased cardiac output b. Acute respiratory distress syndrome (ARDS) c. Increased blood pressure d. Damage to laryngeal nerves D. Tracheostomy tube has several potential complications including bleeding, infection and laryngeal nerve damage. 46. Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the: a. Total volume of circulating whole blood b. Total volume of intravascular plasma c. Permeability of capillary walls d. Permeability of kidney tubules . C. In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost. 47. An 83-year-old woman has several ecchymotic areas on her right arm. The bruises are probably caused by: a. increased capillary fragility and permeability b. increased blood supply to the skin c. self inflicted injury d. elder abuse A. Aging process involves increased capillary fragility and permeability. Older adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise like lesions caused by collection of extravascular blood in loosely structured dermis. 48. Nurse Anna is aware that early adaptation of client with renal carcinoma is: a. Nausea and vomiting b. flank pain c. weight gain d. intermittent hematuria . D. Intermittent pain is the classic sign of renal carcinoma. It is primarily due to capillary erosion by the cancerous growth. 78 aoih0718

Pedia 49. A male client with tuberculosis asks Nurse Brian how long the chemotherapy must be continued. Nurse Brian’s accurate reply would be: a. 1 to 3 weeks b. 6 to 12 months c. 3 to 5 months d. 3 years and more B. Tubercle bacillus is a drug resistant organism and takes a long time to be eradicated. Usually a combination of three drugs is used for minimum of 6 months and at least six months beyond culture conversion. 50. A client has undergone laryngectomy. The immediate nursing priority would be: a. Keep trachea free of secretions b. Monitor for signs of infection c. Provide emotional support d. Promote means of communication . A. Patent airway is the most priority; therefore removal of secretions is necessary.

79 aoih0718

Pedia

Set 02 Medical – Surgical Nursing 1. Mrs. Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client’s lungs indicative of chronic heart failure would be: a. Stridor b. Crackles c. Wheezes d. Friction rubs B. Left sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration 2. Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine: a. Decrease anxiety and restlessness b. Prevents shock and relieves pain c. Dilates coronary blood vessels d. Helps prevent fibrillation of the heart B. Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction, it also decreases apprehension and prevents cardiogenic shock 3. Which of the following should the nurse teach the client about the signs of digitalis toxicity? a. Increased appetite b. Elevated blood pressure c. Skin rash over the chest and back d. Visual disturbances such as seeing yellow spots D. Seeing yellow spots and colored vision are common symptoms of digitalis toxicity 80 aoih0718

Pedia 4. Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help… a. Retard rapid drug absorption b. Excrete excessive fluids accumulated at night c. Prevents sleep disturbances during night d. Prevention of electrolyte imbalance C. When diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently at night 5. What would be the primary goal of therapy for a client with pulmonary edema and heart failure? a. Enhance comfort b. Increase cardiac output c. Improve respiratory status d. Peripheral edema decreased B. The primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output. Pulmonary edema is an acute medical emergency requiring immediate intervention. 6. Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is a characteristic of this type of posturing? a. Upper extremity flexion with lower extremity flexion b. Upper extremity flexion with lower extremity extension c. Extension of the extremities after a stimulus d. Flexion of the extremities after stimulus C. Decerebrate posturing is the extension of the extremities after a stimulus which may occur with upper brain stem injury 7. A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following maybe experienced as side effects of this medication: a. GI bleeding b. Peptic ulcer disease c. Abdominal cramps d. Partial bowel obstruction C. The most frequent side effects of Cascara Sagrada (Laxative) is abdominal cramps and nausea. 8. Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action? a. Monitoring urine output frequently b. Monitoring blood pressure every 4 hours 81 aoih0718

Pedia c. Obtaining serum potassium levels daily d. Obtaining infusion pump for the medication D. Administration of Intravenous Nitroglycerin infusion requires pump for accurate control of medication 9. During the second day of hospitalization of the client after a Myocardial Infarction. Which of the following is an expected outcome? a. Able to perform self-care activities without pain b. Severe chest pain c. Can recognize the risk factors of Myocardial Infarction d. Can Participate in cardiac rehabilitation walking program A. By the 2nd day of hospitalization after suffering a Myocardial Infarction, Clients are able to perform care without chest pain 10. A 68 year old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to: a. Application of elastic stockings to prevent flaccid by muscle b. Use hand roll and extend the left upper extremity on a pillow to prevent contractions c. Use a bed cradle to prevent dorsiflexion of feet d. Do passive range of motion exercise B. The left side of the body will be affected in a right-sided brain attack. 11. Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza’s highest priority would be… a. Hourly urine output b. Temperature c. Able to turn side to side d. Able to sips clear liquid A. After nephrectomy, it is necessary to measure urine output hourly. This is done to assess the effectiveness of the remaining kidney also to detect renal failure early 12. A 64 year old male client with a long history of cardiovascular problem including hypertension and angina is to be scheduled for cardiac catheterization. During pre cardiac catheterization teaching, Nurse Cherry should inform the client that the primary purpose of the procedure is….. a. To determine the existence of CHD b. To visualize the disease process in the coronary arteries c. To obtain the heart chambers pressure d. To measure oxygen content of different heart chambers 82 aoih0718

Pedia B. The lumen of the arteries can be assessed by cardiac catheterization. Angina is usually caused by narrowing of the coronary arteries 13. During the first several hours after a cardiac catheterization, it would be most essential for nurse Cherry to… a. Elevate clients bed at 45° b. Instruct the client to cough and deep breathe every 2 hours c. Frequently monitor client’s apical pulse and blood pressure d. Monitor clients temperature every hour C. Blood pressure is monitored to detect hypotension which may indicate shock or hemorrhage. Apical pulse is taken to detect dysrhythmias related to cardiac irritability. 14. Kate who has undergone mitral valve replacement suddenly experiences continuous bleeding from the surgical incision during postoperative period. Which of the following pharmaceutical agents should Nurse Aiza prepare to administer to Kate? a. Protamine Sulfate b. Quinidine Sulfate c. Vitamin C d. Coumadin A. Protamine Sulfate is used to prevent continuous bleeding in client who has undergone open heart surgery. 15. In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in client with mitral stenosis in teaching plan should include proper use of… a. Dental floss b. Electric toothbrush c. Manual toothbrush d. Irrigation device C. The use of electronic toothbrush, irrigation device or dental floss may cause bleeding of gums, allowing bacteria to enter and increasing the risk of endocarditis. 16. Among the following signs and symptoms, which would most likely be present in a client with mitral gurgitation? a. Altered level of consciousness b. Exceptional Dyspnea c. Increase creatine phospholinase concentration d. Chest pain B. Weight gain due to retention of fluids and worsening heart failure causes exertional dyspnea in clients with mitral regurgitation. 17. Kris with a history of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out whether the current problem is in renal origin, the nurse should assess whether the client has discomfort or pain in the… 83 aoih0718

Pedia a. Urinary meatus b. Pain in the Labium c. Suprapubic area d. Right or left costovertebral angle D. Discomfort or pain is a problem that originates in the kidney. It is felt at the costovertebral angle on the affected side. 18. Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and characteristics, Nurse Perry assesses which signs as the best indicator of renal function. a. Blood pressure b. Consciousness c. Distension of the bladder d. Pulse rate A. Perfusion can be best estimated by blood pressure, which is an indirect reflection of the adequacy of cardiac output. 19. John suddenly experiences a seizure, and Nurse Gina notice that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure? a. Tonic seizure b. Absence seizure c. Myoclonic seizure d. Clonic seizure C. Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle group. 20. Smoking cessation is critical strategy for the client with Burgher’s disease, Nurse Jasmin anticipates that the male client will go home with a prescription for which medication? a. Paracetamol b. Ibuprofen c. Nitroglycerin d. Nicotine (Nicotrol) D. Nicotine (Nicotrol) is given in controlled and decreasing doses for the management of nicotine withdrawal syndrome 21. Nurse Lilly has been assigned to a client with Raynaud’s disease. Nurse Lilly realizes that the etiology of the disease is unknown but it is characterized by: a. Episodic vasospastic disorder of capillaries b. Episodic vasospastic disorder of small veins 84 aoih0718

Pedia c. Episodic vasospastic disorder of the aorta d. Episodic vasospastic disorder of the small arteries D. Raynaud’s disease is characterized by vasospasms of the small cutaneous arteries that involves fingers and toes. 22. Nurse Jamie should explain to male client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because… a. More accurate b. Can be done by the client c. It is easy to perform d. It is not influenced by drugs A. Urine testing provides an indirect measure that maybe influenced by kidney function while blood glucose testing is a more direct and accurate measure 23. Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic therapy, Jessie weighs 205.5 pounds. The nurse could estimate the amount of fluid Jessie has lost… a. 0.3 L b. 1.5 L c. 2.0 L d. 3.5 L C. One liter of fluid approximately weighs 2.2 pounds. A 4.5 pound weight loss equals to approximately 2L. 24. Nurse Donna is aware that the shift of body fluids associated with Intravenous administration of albumin occurs in the process of: a. Osmosis b. Diffusion c. Active transport d. Filtration A. Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration. 25. Myrna a 52 year old client with a fractured left tibia has a long leg cast and she is using crutches to ambulate. Nurse Joy assesses for which sign and symptom that indicates complication associated with crutch walking? a. Left leg discomfort b. Weak biceps brachii c. Triceps muscle spasm d. Forearm weakness D. Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the axillae. 85 aoih0718

Pedia 26. Which of the following statements should the nurse teach the neutropenic client and his family to avoid? a. Performing oral hygiene after every meal b. Using suppositories or enemas c. Performing perineal hygiene after each bowel movement d. Using a filter mask B. Neutropenic client is at risk for infection especially bacterial infection of the gastrointestinal and respiratory tract. 27. A female client is experiencing painful and rigid abdomen and is diagnosed with perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is inserted. The nurse should place the client before surgery in a. Sims position b. Supine position c. Semi-fowlers position d. Dorsal recumbent position C. Semi-fowlers position will localize the spilled stomach contents in the lower part of the abdominal cavity. 28. Which nursing intervention ensures adequate ventilating exchange after surgery? a. Remove the airway only when client is fully conscious b. Assess for hypoventilation by auscultating the lungs c. Position client laterally with the neck extended d. Maintain humidified oxygen via nasal canula C. Positioning the client laterally with the neck extended does not obstruct the airway so that drainage of secretions and oxygen and carbon dioxide exchange can occur. 29. George who has undergone thoracic surgery has chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in water-seal chamber, the nurse should… a. “Strip” the chest tube catheter b. Check the system for air leaks c. Recognize the system is functioning correctly d. Decrease the amount of suction pressure B. Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion. 30. A client who has been diagnosed of hypertension is being taught to restrict intake of sodium. The nurse would know that the teachings are effective if the client states that… a. I can eat celery sticks and carrots b. I can eat broiled scallops c. I can eat shredded wheat cereal 86 aoih0718

Pedia d. I can eat spaghetti on rye bread C. Wheat cereal has a low sodium content. 31. A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulted to ascites. The nurse should be aware that the ascites is most likely the result of increased… a. Pressure in the portal vein b. Production of serum albumin c. Secretion of bile salts d. Interstitial osmotic pressure A. Enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting to ascites. 32. A newly admitted client is diagnosed with Hodgkin’s disease undergoes an excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess first after the procedure? a. Vital signs b. Incision site c. Airway d. Level of consciousness C. Assessing for an open airway is the priority. The procedure involves the neck, the anesthesia may have affected the swallowing reflex or the inflammation may have closed in on the airway leading to ineffective air exchange. 33. A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock? a. Systolic blood pressure less than 90mm Hg b. Pupils unequally dilated c. Respiratory rate of 4 breath/min d. Pulse rate less than 60bpm A. Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg. 34. Nurse Lucy is planning to give pre operative teaching to a client who will be undergoing rhinoplasty. Which of the following should be included? a. Results of the surgery will be immediately noticeable postoperatively b. Normal saline nose drops will need to be administered preoperatively c. After surgery, nasal packing will be in place 8 to 10 days d. Aspirin containing medications should not be taken 14 days before surgery D. Aspirin containing medications should not be taken 14 days before surgery to decrease the risk of bleeding. 35. Paul is admitted to the hospital due to metabolic acidosis caused by Diabetic ketoacidosis (DKA). The nurse prepares which of the following medications as an initial treatment for this problem? 87 aoih0718

Pedia a. Regular insulin b. Potassium c. Sodium bicarbonate d. Calcium gluconate A. Metabolic acidosis is anaerobic metabolism caused by lack of ability of the body to use circulating glucose. Administration of insulin corrects this problem. 36. Dr. Marquez tells a client that an increase intake of foods that are rich in Vitamin E and beta-carotene are important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are: a. Fish and fruit jam b. Oranges and grapefruit c. Carrots and potatoes d. Spinach and mangoes D. Beta-carotene and Vitamin E are antioxidants which help to inhibit oxidation. Vitamin E is found in the following foods: wheat germ, corn, nuts, seeds, olives, spinach, asparagus and other green leafy vegetables. Food sources of beta-carotene include dark green vegetables, carrots, mangoes and tomatoes. 37. A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client that after every meals, the client should… a. Rest in sitting position b. Take a short walk c. Drink plenty of water d. Lie down at least 30 minutes A. Gravity speeds up digestion and prevents reflux of stomach contents into the esophagus. 38. After gastroscopy, an adaptation that indicates major complication would be: a. Nausea and vomiting b. Abdominal distention c. Increased GI motility d. Difficulty in swallowing B. Abdominal distension may be associated with pain, may indicate perforation, a complication that could lead to peritonitis. 39. A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood when the client tells a family member that: a. “Most people need to eat a high protein diet for 12 months after surgery” b. “I should not eat those foods that upset me before the surgery” 88 aoih0718

Pedia c. “I should avoid fatty foods as long as I live” d. “Most people can tolerate regular diet after this type of surgery” D. It may take 4 to 6 months to eat anything, but most people can eat anything they want. 40. Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs and symptoms related to Hepatitis that may develop. The one that should be reported immediately to the physician is: a. Restlessness b. Yellow urine c. Nausea d. Clay- colored stools D. Clay colored stools are indicative of hepatic obstruction. 41. Which of the following antituberculosis drugs can damage the 8th cranial nerve? a. Isoniazid (INH) b. Paraoaminosalicylic acid (PAS) c. Ethambutol hydrochloride (myambutol) d. Streptomycin D. Streptomycin is an aminoglycoside and damage on the 8th cranial nerve (ototoxicity) is a common side effect of aminoglycosides. 42. The client asks Nurse Annie the causes of peptic ulcer. Nurse Annie responds that recent research indicates that peptic ulcers are the result of which of the following: a. Genetic defect in gastric mucosa b. Stress c. Diet high in fat d. Helicobacter pylori infection D. Most peptic ulcer is caused by Helicopter pylori which is a gram negative bacterium. 43. Ryan has undergone subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery? a. Bile green b. Bright red c. Cloudy white d. Dark brown D. 12 to 24 hours after subtotal gastrectomy gastric drainage is normally brown, which indicates digested food.

89 aoih0718

Pedia 44. Nurse Joan is assigned to come for client who has just undergone eye surgery. Nurse Joan plans to teach the client activities that are permitted during the post operative period. Which of the following is best recommended for the client? a. Watching circus b. Bending over c. Watching TV d. Lifting objects C. Watching TV is permissible because the eye does not need to move rapidly with this activity, and it does not increase intraocular pressure. 45. A client suffered from a lower leg injury and seeks treatment in the emergency room. There is a prominent deformity to the lower aspect of the leg, and the injured leg appears shorter that the other leg. The affected leg is painful, swollen and beginning to become ecchymotic. The nurse interprets that the client is experiencing: a. Fracture b. Strain c. Sprain d. Contusion A. Common signs and symptoms of fracture include pain, deformity, shortening of the extremity, crepitus and swelling. 46. Nurse Jenny is instilling an otic solution into an adult male client left ear. Nurse Jenny avoids doing which of the following as part of the procedure a. Pulling the auricle backward and upward b. Warming the solution to room temperature c. Pacing the tip of the dropper on the edge of ear canal d. Placing client in side lying position C. The dropper should not touch any object or any part of the client’s ear. 47. Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptom? a. Absence of drainage from the ileostomy for 6 or more hours b. Passage of liquid stool in the stoma c. Occasional presence of undigested food d. A temperature of 37.6 °C A. Sudden decrease in drainage or onset of severe abdominal pain should be reported immediately to the physician because it could mean that obstruction has been developed. 48. Jerry has diagnosed with appendicitis. He develops a fever, hypotension and tachycardia. The nurse suspects which of the following complications? a. Intestinal obstruction 90 aoih0718

Pedia b. Peritonitis c. Bowel ischemia d. Deficient fluid volume B. Complications of acute appendicitis are peritonitis, perforation and abscess development 49. Which of the following compilations should the nurse carefully monitors a client with acute pancreatitis. a. Myocardial Infarction b. Cirrhosis c. Peptic ulcer d. Pneumonia D. A client with acute pancreatitis is prone to complications associated with respiratory system. 50. Which of the following symptoms during the icteric phase of viral hepatitis should the nurse expect the client to inhibit? a. Watery stool b. Yellow sclera c. Tarry stool d. Shortness of breath B. Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy.

Set 03 Medical- Surgical Nursing 1. A client is scheduled for insertion of an inferior vena cava (IVC) filter. Nurse Patricia consults the physician about withholding which regularly scheduled medication on the day before the surgery? a. Potassium Chloride b. Warfarin Sodium c. Furosemide d. Docusate . B. In preoperative period, the nurse should consult with the physician about withholding Warfarin Sodium to avoid occurrence of hemorrhage. 2. A nurse is planning to assess the corneal reflex on unconscious client. Which of the following is the safest stimulus to touch the client’s cornea? a. Cotton buds 91 aoih0718

Pedia b. Sterile glove c. Sterile tongue depressor d. Wisp of cotton D. A client who is unconscious is at greater risk for corneal abrasion. For this reason, the safest way to test the cornel reflex is by touching the cornea lightly with a wisp of cotton. 3. A female client develops an infection at the catheter insertion site. The nurse in charge uses the term “iatrogenic” when describing the infection because it resulted from: a. Client’s developmental level b. Therapeutic procedure c. Poor hygiene d. Inadequate dietary patterns B. Iatrogenic infection is caused by the heath care provider or is induced inadvertently by medical treatment or procedures. 4. Nurse Carol is assessing a client with Parkinson’s disease. The nurse recognize bradykinesia when the client exhibits: a. Intentional tremor b. Paralysis of limbs c. Muscle spasm d. Lack of spontaneous movement D. Bradykinesia is slowing down from the initiation and execution of movement. 5. A client who suffered from automobile accident complains of seeing frequent flashes of light. The nurse should expect: a. Myopia b. Detached retina c. Glaucoma d. Scleroderma B. This symptom is caused by stimulation of retinal cells by ocular movement.

6. Kate with severe head injury is being monitored by the nurse for increasing intracranial pressure (ICP). Which finding should be most indicative sign of increasing intracranial pressure? a. Intermittent tachycardia b. Polydipsia c. Tachypnea d. Increased restlessness 92 aoih0718

Pedia . D. Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system. 7. A hospitalized client had a tonic-clonic seizure while walking in the hall. During the seizure the nurse priority should be: a. Hold the clients arms and leg firmly b. Place the client immediately to soft surface c. Protects the client’s head from injury d. Attempt to insert a tongue depressor between the client’s teeth C. Rhythmic contraction and relaxation associated with tonic-clonic seizure can cause repeated banging of head. 8. A client has undergone right pneumonectomy. When turning the client, the nurse should plan to position the client either: a. Right side-lying position or supine b. High fowlers c. Right or left side lying position d. Low fowler’s position A. Right side lying position or supine position permits ventilation of the remaining lung and prevent fluid from draining into sutured bronchial stump. 9. Nurse Jenny should caution a female client who is sexually active in taking Isoniazid (INH) because the drug has which of the following side effects? a. Prevents ovulation b. Has a mutagenic effect on ova c. Decreases the effectiveness of oral contraceptives d. Increases the risk of vaginal infection C. Isoniazid (INH) interferes in the effectiveness of oral contraceptives and clients of childbearing age should be counseled to use an alternative form of birth control while taking this drug. 10. A client has undergone gastrectomy. Nurse Jovy is aware that the best position for the client is: a. Left side lying b. Low fowler’s c. Prone d. Supine . B. A client who has had abdominal surgery is best placed in a low fowler’s position. This relaxes abdominal muscles and provides maximum respiratory and cardiovascular function. 11. During the initial postoperative period of the client’s stoma. The nurse evaluates which of the following observations should be reported immediately to the physician? a. Stoma is dark red to purple 93 aoih0718

Pedia b. Stoma is oozes a small amount of blood c. Stoma is lightly edematous d. Stoma does not expel stool A. Dark red to purple stoma indicates inadequate blood supply. 12. Kate which has diagnosed with ulcerative colitis is following physician’s order for bed rest with bathroom privileges. What is the rationale for this activity restriction? a. Prevent injury b. Promote rest and comfort c. Reduce intestinal peristalsis d. Conserve energy C. The rationale for activity restriction is to help reduce the hypermotility of the colon. 13. Nurse KC should regularly assess the client’s ability to metabolize the total parenteral nutrition (TPN) solution adequately by monitoring the client for which of the following signs: a. Hyperglycemia b. Hypoglycemia c. Hypertension d. Elevate blood urea nitrogen concentration A. During Total Parenteral Nutrition (TPN) administration, the client should be monitored regularly for hyperglycemia. 14. A female client has an acute pancreatitis. Which of the following signs and symptoms the nurse would expect to see? a. Constipation b. Hypertension c. Ascites d. Jaundice D. Jaundice may be present in acute pancreatitis owing to obstruction of the biliary duct. 15. A client is suspected to develop tetany after a subtotal thyroidectomy. Which of the following symptoms might indicate tetany? a. Tingling in the fingers b. Pain in hands and feet c. Tension on the suture lines d. Bleeding on the back of the dressing A. Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or removed. 94 aoih0718

Pedia 16. A 58 year old woman has newly diagnosed with hypothyroidism. The nurse is aware that the signs and symptoms of hypothyroidism include: a. Diarrhea b. Vomiting c. Tachycardia d. Weight gain D. Typical signs of hypothyroidism includes weight gain, fatigue, decreased energy, apathy, brittle nails, dry skin, cold intolerance, constipation and numbness. 17. A client has undergone for an ileal conduit, the nurse in charge should closely monitor the client for occurrence of which of the following complications related to pelvic surgery? a. Ascites b. Thrombophlebitis c. Inguinal hernia d. Peritonitis B. After a pelvic surgery, there is an increased chance of thrombophlebitits owing to the pelvic manipulation that can interfere with circulation and promote venous stasis. 18. Dr. Marquez is about to defibrillate a client in ventricular fibrillation and says in a loud voice “clear”. What should be the action of the nurse? a. Places conductive gel pads for defibrillation on the client’s chest b. Turn off the mechanical ventilator c. Shuts off the client’s IV infusion d. Steps away from the bed and make sure all others have done the same D. For the safety of all personnel, if the defibrillator paddles are being discharged, all personnel must stand back and be clear of all the contact with the client or the client’s bed. 19. A client has been diagnosed with glomerulonephritis complains of thirst. The nurse should offer: a. Juice b. Ginger ale c. Milk shake d. Hard candy D. Hard candy will relieve thirst and increase carbohydrates but does not supply extra fluid. 20. A client with acute renal failure is aware that the most serious complication of this condition is: a. Constipation b. Anemia 95 aoih0718

Pedia c. Infection d. Platelet dysfunction C. Infection is responsible for one third of the traumatic or surgically induced death of clients with renal failure as well as medical induced acute renal failure (ARF). 21. Nurse Karen is caring for clients in the OR. The nurse is aware that the last physiologic function that the client loss during the induction of anesthesia is:

a. Consciousness b. Gag reflex c. Respiratory movement d. Corneal reflex C. There is no respiratory movement in stage 4 of anesthesia, prior to this stage, respiration is depressed but present. 22. The nurse is assessing a client with pleural effusion. The nurse expect to find: a. Deviation of the trachea towards the involved side b. Reduced or absent of breath sounds at the base of the lung c. Moist crackles at the posterior of the lungs d. Increased resonance with percussion of the involved area B. Compression of the lung by fluid that accumulates at the base of the lungs reduces expansion and air exchange. 23. A client admitted with newly diagnosed with Hodgkin’s disease. Which of the following would the nurse expect the client to report? a. Lymph node pain b. Weight gain c. Night sweats d. Headache . C. Assessment of a client with Hodgkin’s disease most often reveals enlarged, painless lymph node, fever, malaise and night sweats. 24. A client has suffered from fall and sustained a leg injury. Which appropriate question would the nurse ask the client to help determine if the injury caused fracture? a. “Is the pain sharp and continuous?” b. “Is the pain dull ache?” c. “Does the discomfort feel like a cramp?” d. “Does the pain feel like the muscle was stretched?” A. Fractured pain is generally described as sharp, continuous, and increasing in frequency. 96 aoih0718

Pedia 25. The Nurse is assessing the client’s casted extremity for signs of infection. Which of the following findings is indicative of infection? a. Edema b. Weak distal pulse c. Coolness of the skin d. Presence of “hot spot” on the cast D. Signs and symptoms of infection under a casted area include odor or purulent drainage and the presence of “hot spot” which are areas on the cast that are warmer than the others. 26. Nurse Rhia is performing an otoscopic examination on a female client with a suspected diagnosis of mastoiditis. Nurse Rhia would expect to note which of the following if this disorder is present? a. Transparent tympanic membrane b. Thick and immobile tympanic membrane c. Pearly colored tympanic membrane d. Mobile tympanic membrane B. Otoscopic examnation in a client with mastoiditis reveals a dull, red, thick and immobile tymphanic membrane with or without perforation. 27. Nurse Jocelyn is caring for a client with nasogastric tube that is attached to low suction. Nurse Jocelyn assesses the client for symptoms of which acid-base disorder? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis D. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid which is a potent acid in the body. 28. A male adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. Which of the following values should be negative if the CSF is normal? a. Red blood cells b. White blood cells c. Insulin d. Protein . A. The adult with normal cerebrospinal fluid has no red blood cells. 29. A client is suspected of developing diabetes insipidus. Which of the following is the most effective assessment? a. Taking vital signs every 4 hours 97 aoih0718

Pedia b. Monitoring blood glucose c. Assessing ABG values every other day d. Measuring urine output hourly D. Measuring the urine output to detect excess amount and checking the specific gravity of urine samples to determine urine concentration are appropriate measures to determine the onset of diabetes insipidus. 30. A 58 year old client is suffering from acute phase of rheumatoid arthritis. Which of the following would the nurse in charge identify as the lowest priority of the plan of care? a. Prevent joint deformity b. Maintaining usual ways of accomplishing task c. Relieving pain d. Preserving joint function B. The nurse should focus more on developing less stressful ways of accomplishing routine task. 31. Among the following, which client is autotransfusion possible? a. Client with AIDS b. Client with ruptured bowel c. Client who is in danger of cardiac arrest d. Client with wound infection . C. Autotransfusion is acceptable for the client who is in danger of cardiac arrest. 32. Which of the following is not a sign of thromboembolism? a. Edema b. Swelling c. Redness d. Coolness . D. The client with thromboembolism does not have coolness. 33. Nurse Becky is caring for client who begins to experience seizure while in bed. Which action should the nurse implement to prevent aspiration? a. Position the client on the side with head flexed forward b. Elevate the head c. Use tongue depressor between teeth d. Loosen restrictive clothing A. Positioning the client on one side with head flexed forward allows the tongue to fall forward and facilitates drainage secretions therefore prevents aspiration. 98 aoih0718

Pedia 34. A client has undergone bone biopsy. Which nursing action should the nurse provide after the procedure? a. Administer analgesics via IM b. Monitor vital signs c. Monitor the site for bleeding, swelling and hematoma formation d. Keep area in neutral position C. Nursing care after bone biopsy includes close monitoring of the punctured site for bleeding, swelling and hematoma formation. 35. A client is suffering from low back pain. Which of the following exercises will strengthen the lower back muscle of the client? a. Tennis b. Basketball c. Diving d. Swimming D. Walking and swimming are very helpful in strengthening back muscles for the client suffering from lower back pain. 36. A client with peptic ulcer is being assessed by the nurse for gastrointestinal perforation. The nurse should monitor for: a. (+) guaiac stool test b. Slow, strong pulse c. Sudden, severe abdominal pain d. Increased bowel sounds C. Sudden, severe abdominal pain is the most indicative sign of perforation. When perforation of an ulcer occurs, the nurse maybe unable to hear bowel sounds at all. 37. A client has undergone surgery for retinal detachment. Which of the following goal should be prioritized? a. Prevent an increase intraocular pressure b. Alleviate pain c. Maintain darkened room d. Promote low-sodium diet A. After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal. 38. A Client with glaucoma has been prescribed with miotics. The nurse is aware that miotics is for: a. Constricting pupil b. Relaxing ciliary muscle c. Constricting intraocular vessel 99 aoih0718

Pedia d. Paralyzing ciliary muscle A. Miotic agent constricts the pupil and contracts ciliary muscle. These effects widen the filtration angle and permit increased out flow of aqueous humor. 39. When suctioning an unconscious client, which nursing intervention should the nurse prioritize in maintaining cerebral perfusion? a. Administer diuretics b. Administer analgesics c. Provide hygiene d. Hyperoxygenate before and after suctioning D. It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and to maintain cerebral perfusion. 40. When discussing breathing exercises with a postoperative client, Nurse Hazel should include which of the following teaching? a. Short frequent breaths b. Exhale with mouth open c. Exercise twice a day d. Place hand on the abdomen and feel it rise D. Abdominal breathing improves lungs expansion 41. Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s comfort, the nurse should: a. Maintain room humidity below 40% b. Place top sheet on the client c. Limit the occurrence of drafts d. Keep room temperature at 80 degrees C. A Client with burns is very sensitive to temperature changes because heat is loss in the burn areas. 42. Nurse Trish is aware that temporary heterograft (pig skin) is used to treat burns because this graft will: a. Relieve pain and promote rapid epithelialization b. Be sutured in place for better adherence c. Debride necrotic epithelium d. Concurrently used with topical antimicrobials A. The graft covers the nerve endings, which reduces pain and provides framework for granulation. 43. Mark has multiple abrasions and a laceration to the trunk and all four extremities says, “I can’t eat all this food”. The food that the nurse should suggest to be eaten first should be: a. Meat loaf and coffee 100 aoih0718

Pedia b. Meat loaf and strawberries c. Tomato soup and apple pie d. Tomato soup and buttered bread B. Meat provides proteins and the fruit proteins vitamin C that both promote wound healing. 44. Tony returns form surgery with permanent colostomy. During the first 24 hours the colostomy does not drain. The nurse should be aware that: a. Proper functioning of nasogastric suction b. Presurgical decrease in fluid intake c. Absence of gastrointestinal motility d. Intestinal edema following surgery C. This is primarily caused by the trauma of intestinal manipulation and the depressive effects anesthetics and analgesics. 45. When teaching a client about the signs of colorectal cancer, Nurse Trish stresses that the most common complaint of persons with colorectal cancer is: a. Abdominal pain b. Hemorrhoids c. Change in caliber of stools d. Change in bowel habits D. Constipation, diarrhea, and/or constipation alternating with diarrhea are the most common symptoms of colorectal cancer. 46. Louis develops peritonitis and sepsis after surgical repair of ruptures diverticulum. The nurse in charge should expect an assessment of the client to reveal: a. Tachycardia b. Abdominal rigidity c. Bradycardia d. Increased bowel sounds B. With increased intraabdominal pressure, the abdominal wall will become tender and rigid. 47. Immediately after liver biopsy, the client is placed on the right side, the nurse is aware that that this position should be maintained because it will: a. Help stop bleeding if any occurs b. Reduce the fluid trapped in the biliary ducts c. Position with greatest comfort d. Promote circulating blood volume 101 aoih0718

Pedia A. Pressure applied in the puncture site indicates that a biliary vessel was puncture which is a common complication after liver biopsy. 48. Tony has diagnosed with hepatitis A. The information from the health history that is most likely linked to hepatitis A is: a. Exposed with arsenic compounds at work b. Working as local plumber c. Working at hemodialysis clinic d. Dish washer in restaurants B. Hepatitis A is primarily spread via fecal-oral route. Sewage polluted water may harbor the virus. 49. Nurse Trish is aware that the laboratory test result that most likely would indicate acute pancreatitis is an elevated: a. Serum bilirubin level b. Serum amylase level c. Potassium level d. Sodium level B. Amylase concentration is high in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed and also it distinguishes pancreatitis from other acute abdominal problems. 50. Dr. Marquez orders serum electrolytes. To determine the effect of persistent vomiting, Nurse Trish should be most concerned with monitoring the: a. Chloride and sodium levels b. Phosphate and calcium levels c. Protein and magnesium levels d. Sulfate and bicarbonate levels A. Sodium, which is concerned with the regulation of extracellular fluid volume, it is lost with vomiting. Chloride, which balances cations in the extracellular compartments, is also lost with vomiting, because sodium and chloride are parallel electrolytes, hyponatremia will accompany.

102 aoih0718