Summary Exam 5 NUR 230

Cardiac
o Meds:
Lasix-I & O , K enriched foods
Digoxin
increases contractility, slows heart. Dangerous drug

with narrow window of safety.

Take apical pulse x 1 min.
If vomits, do not repeat dose.
Dig toxicity: anorexia, nausea, vomiting, diarrhea, visual

disturbances (yellow vision), bradycardia

o Closely monitor for toxicity if on antibiotics
o CHF- causes, s/s, nursing interventions, treatment
S & S: tachycardia, diaphoretic, weight Gain, cardiac output

decreased due to fluid overload

If in CHF, may require O2 during procdures
congenital defects: s/s, nursing intervention
ASD- may be asymtomatic but can develop CHF. Oxygenated
blood flows back in the right atrium. Usually with exercise
intolerance. Diastolic murmur, risk for atrial dysrhythmias.
Can be treated with a surgical patch closure or cardiac cath can

now be performed to dispatch a closure device.

VSD-Can cause hypertrophy of the right ventricle from the
pressure from the lungs and the left to right shunting. CHF is

common. There is a loud holosystolic murmer.

Coarctation of the aorta narrowing near the insertion of the
ductus arteriosus which results in increased pressure proximal
to the defect ( head and upper extremities) and decreased
pressure distal to the obstruction (body and extremiteis).
Patient presents with increased blood pressure and bounding
pulses in the arms, weak or absent femoral pulses and cool lower

extremities with lower blood pressure.

Tetralogy of Fallot: Four defects are ventricular septal defect,
pulmonic stenosis, overriding aortal and right ventricular

hypertrophy. Manifestations are cyanotic at birth. It can start

off mild and progress with time. There is a systolic murmur,
moderate in intensity. There can be acute episodes of
cyanosis and hypoxia called blue spells or tet you may see
elevated HR and RR. When these spells occur you will place the
infant in the knee chest position. You will see older children will
automatically go into this position. Treatment is usually done
within the first year of life. Mortality is less then 3 percent.

Congestive heart failure is a concern postoperatively.

Post-op care

o Rheumatic fever: causes, s/s, nursing interventions, treatment

Inflammatory disease occurs after Group A
-hemolytic streptococcal pharyngitis
Treatment of streptococcal tonsillitis/pharyngitis
Antibiotics
Anti-inflammatories
Bedrest
o Kawasaki Disease: causes, s/s, nursing interventions, treatment
Etiology is unknown, though not known to spread from person to

person it is see in geographic and seasonal outbreaks.

Monocutaneous lymph node syndrome (enlarged lymph nodes)
Acute systemic vasculitis of unknown cause (Inflammation of

the lining of arteries and veins)

75% of cases are in children under age 5
Self-limiting
Increased risk of coronary artery aneurysm
Acute Phase-abrupt high fever not responsive to antibiotics,
irritability, rash, red eyes, peeling hands & feet, irritability, red

tongue, conjuctivitis
Subacute phase- resolution of fever and lasts until all clinical
signs of KD have disappeared. This phase is where the child is

at greatest risk for developing coronary artery aneurysms.

Convalescent phase-all signs and symptoms have resolved but
laboratory values remain abnormal until around 6 to 8 weeks
later

Treatment
Globulins- to reduce risk of coronary artery lesions and
aneurysyms
Aspirin- antiplatelet agent
nursing interventions
light weight clothing
monitor temperature
nutrition: bland foods, avoid citrus or other irritating
foods

Cardiac procedures: nursing interventions for developmental levels

Nursing interventions
Postprocdural care- Check pulses especially where?? below the
catherization site. Temp and color of the extremity Why? Can

indicate arterial obstruction

Vital Signs, Why? Why check a pulse for on full minute
(dysrhythmia and bradycardia) B/P can indicate what?
Hypotension which can indicate what? (hemorrhage) Remember
its a later sign in a child, children are able to maintain blood
pressure longer then adults. Dressing check why? Bleeding or
hematoma, Fluid intake (dehydration due to npo and diuretic

action of the dyes, and blood glucose why??

Discharge information

Respiratory

Growth and Development issues

o How does ages affect anatomy and predispose to respiratory problems
Causes, s/s, nursing interventions, education, and treatment for the
following:
o Epiglottis
o

Signs: leaning forward (tripod position), drooling of saliva, cherry red

epiglottitis, sore throat, pain on swallowing

No visualization of throat
Considered medical emergency(edema in this area can obstruct
airway and occlude trachea)

o LTB: Viral infection that causes inflammation, edema and narrowing of

larynx, trachea and bronchi. Inflammation and narrowing of the airway
causes inspiratory stridor and suprasternal retractions. Treatment:IV
fluids, steroids, nebulized racemic epinephrine
o Pharyngitis
May be caused by strep
Can return to school after 24 hours of antibiotics
No propping the bottle
Stay away from cigarette smoke
Not putting the baby to sleep with the bottle
o Otitis media
Fluid back ups in Eustachian tube
No propping of bottle
No laying flat in crib with bottle
o Bronchiolitis (RSV)
Most frequent cause of hospitalization for children less than 1
Why issue for infants
Treatment
May require hospitalization
Management of symtoms i.e. cool humidified oxygen,

hydration
Ribavarin may be used, but there is controversy
regarding the use due to cost, aerosol route of
administration which may cause potential toxic effects in

exposed health care personnel, efficacy

Requires contact isolation

o Asthma
Chronic inflammatory disorder of airways
Classification system for asthma (4 classifications)
Triggers for asthma
Smoke, chemicals
Exercise
Cold air
Pets & other animals
Foods.
Emotions

SOB with shortness with restricted breath sounds is an

ominous sign & imminent respiratory arrest

Treatment
Allergen control
Drug therapy
Chest physiotherapy
o Cystic fibrosis- Multisystem disorder of exocrine glands, leading to
increased production of thick mucus in bronchioles, small intestine and
pancreatic and bile duct. Increased viscosity of secretions obstructs
small passageway of these organs and interferes with normal
pulmonary and digestive functioning. Pancreatic duct becomes clogged
due to thick mucus secretions which prevent pancreatic enzyme from
reaching duodenum impairing digestion and absorption. Small intestine
in the absence of pancreatic enzyme are unable to absorb fats and
protein; thus growth and puberty are retarded.
Autosomal recessive trait
1:4 chance of having disease
First sign may be meconium ileus( not passing meconium stool)
Diagnosis made by positive sweat test(chloride concentration

greater than 60 meq/L)

Use CPT either manually or vest(2-4 times a day)
Mucus flutter device(a small hand held plastic pipe with
stainless steel ball on the inside) facilitates the removal of

secretions
May have pulmonary infections-treat with IV antibiotics
GI-pancrease before each meal
High protein, high caloric diet
Family support
Can have scheduled immunizations & flu vaccine
Stools are frothy and foul smelling, malnutrition and failure to
thrive is common. Deficiency of vitamin ADEK which can result
in easy bruising, bleeding and anemia are common.

Genitourinary
o Glomerulonephritis
Most common caused by strep

Oliguria
Edema
Hypertension and circulatory congestion
Hematuria
Bleeding in upper urinary tractsmoky urine or tea

colored
Proteinuria
Increased amount of protein = increased severity of

renal disease
o Nephrotic syndrome
Facial edema, weight gain, 3+ proteinuria
Massive proteinura, hypoalbuminemia, hyperlipemia and

edema
Bedrest
Diet
Low-to-moderate protein
Sodium restrictions when large amount of edema present
Steroids 2 mg/kg divided into BID doses
Prednisone is drug of choice (least expensive and safest)
Immunosuppressant therapy (Cytoxan)
Diuretics
Enuresis
Definition: inappropriate voiding 2 times a week for three

months
Hypospadias/ epispadias
Do not circumcise
UTI: tx-cotton panties, no bubble baths, increase fluids

Always check 5 Ps
Immobolization causes venous status
Clubfoot: tx is serial casting changed every one to two weeks &

will require tx for life

Juvenile idiopathic arthritis

Musculoskeletal

Treatment

Congential hip dysplasia

Pavlik harness is used which the child wears 23 hours a day.
Parents should be taught o massage skin once a day.

Duchennes muscular dystrophy

Genetic so parents should be tested.
Usually die by school age.

Scoliosis
o Brace
o May need rod placement
ICU, log rolling

Neurological assessment components- normal vs. abnormal signs

Neuro

How often are you assessing?

Vital signs (HR, RR, BP) What happens when intracranial
pressure increase?
Glasgow Coma scale: eye, verbal, motor
What is considered a neurosurgical emergency?
Fixed and dilated pupils
Remember what reflexes are normal. The moro, tonic neck,
and withdrawal are normal in a two month old but should go
away in the next 3 months. If the reflexes are present at
the correct age, this means that the infant/ child has good
neurological health.
How do you assess LOC in different age groups?
In infants and toddlers, you have to look at their behavior.
Does the infant recognize their mother or father? An infant
with a very shrill cat-like cry is not normal. Is the infant
irritable? Eating?

Decerebrate and decorticate posturing. Decerebrate is

posturing away from the body and decorticate is towards
the body.

Glascow coma scale (3 is very bad) There is a Glascow coma

scale for pediatrics. The adult scale should not be used.
Scores range from 15-3.

Increased Intracranial Pressure

o Factors causing it- head injury from motor vehicle accident,
accident in home, tumor, hydrocephalus.
o Signs and symptoms of various age groups
High pitched cry in infant
Difference in coma, stupor, obtunded
o Nursing responsibilities
Assessment of pain: agitation and restlessness
Non stimulating, quiet environment,
Assessment and documentation.
o Medical interventions
May require intubation and a possible medically induced coma.
Intracranial pressure monitoring may also be done. Keep quiet.
Do not suction or stimulate coughing which increases

intracranial pressure.
Head injuries
o Complications
The biggest concern is increased intracranial pressure. If an
accident scene, always remember to stabilize the neck.
o Nursing considerations
Near Drowning/ Drowning
o Pathophysiology of drowning
Main issue is hypoxia. Perform CPR immediately.
The outcome is better the less time the child was hypoxic.
Requires hospital admission. If the child is alert and appears
ok, the child should still be monitored for at least 24 hours.
o Therapeutic management and nursing considerations

The outcome is not good if the child was without oxygen for
more 4 minutes, the child may die or be in a vegetative state.
Family support is required. There will be a lot of feelings, guilt
and parents may blame the other parent or other person who
was supposed to be watching child.

Hydrocephalus
o What is it and the causes? Overproduction of CSF due to
blockage.
o Clinical manifestations Increased head circumference.
Irritability, Setting sun eyes. Nausea & vomiting.
o Shunts
Ventro-peritoneal shunt. Risk for infection.. Watch for signs
of infection and increasing head circumference. May need
revision as child grows and if becomes infected.
o Pre-op and post-op nursing care
Education for parents: May need revisions as child grows.
Watch for signs of infection.

Menigitis
Inflammation of meninges
S/S: irritability, anorexia, nuchal rigidity, positive Kernigs sign,
coma
Tx: ventilator, environment, antibiotics, assess neuro status
Spina Bifida
o Types
Menigocele, myelomenigocele.
What is the prevention of neural tube defects? Folic acid.
o Clinical manifestations
May be paralyzed from waist down. Does not have bladder or bowel

control. Baby should be born by C-section. Do not want the sac to

rupture. If ruptures, have increased rick for infection. When
delivered, place sterile wet gauze dressing over the sac. Baby must be
in prone position.
o Pre-op and post-op nursing care

Protect from infection. Keep sac intact and sterile.

o Latex
Increased risk for latex allergies. Use latex free products from the
birth and on.

Cerebral Palsy
o Chronic disability with impaired muscle movement
o Causes
o Types- and their clinical manifestations
Spactic, dyskinetic
o Nursing considerations
There is a wide variation in CP. Sometimes people think that the child

is retarded, but that is a generalization. CP child may not have an IQ

deficit.
May need to have jaw thrust to swallow. Requires patience to develop
the swallowing reflex.
Seizure disorders
o Triggers
Smell, sound, may have an aura, extreme tiredness.
o Nurses role during seizure
Protect from injury. Document the seizure.
Febrile Seizures
o Why? High temperature.
o Nursing implications
Education. Usually do not need seizure medications. Will monitor and

send home from the hospital in a day.

Reye Syndrome
o Causes usually followed a viral infection and the use of
aspirin to control fever during the infection.
o Encephalopathy so child will be in coma

o Tx: admitted to ICU, airway (on ventilator), reduced

maintenance fluids, quiet atmosphere with dim lights,
reduced stimulation

Osteosarcoma
o Most common type of bone cancer usually in arm, leg, or pelvis
o More common in males between ages of 10-30
o Pain at tumor site

Wilms tumor:
o Tumor in kidney usually developed in embryo
o Usually detected when bathing and feel a mass in abdomen
o do not palpate
o Requires surgery & chemotherapy

Retinoblastoma.:
o Mutation of the cells of the retina resulting in a malignant
tumor
o White instead of red in photos.. called white reflex
o Refer to opthalmologist