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Pediatrics
Term Review
Cystic Fibrosis
• Chronically ill children
with respiratory issues
-Frequent chronic
infections
• Thick mucous secretions
• Absorption issues
• Shortened life
expectancy- America
37.4 years
• Anglosaxon children
• Need lung transplant
Cerebral Palsey
• Caused by damage to
motor control center
of the brain while it is
developing
• Causes motor issues,
visual impairments
• No cure
• High prevalence of
epilepsy
• Lifetime of physical
therapy to maintain
optimal function
Sickle Cell Anemia
• Genetic adaptation to
malaria
• Primarily affects African
American’s
• Affected children have
episodes of severe pain
• Require surgery to insert
port and often remove
spleen
• These children are very sick
and in a lot of pain
Crohns Disease
• Inflammatory
disorder affecting
entire GI tract
• Abd pain
• Bloody stool
• Trouble with
nutrition
• Often require
colostomy
Crohn’s Disease
• Bowel is attached to
abdominal wall creating a
“stoma” so that feces can
pass freely into a collection
bag
Asthma
• Chronic inflammatory
disease causing a
narrowing of the
lower airways
• This narrowing
causes wheezing or
whistling sound
• http://www.youtube.
com/watch?v=-
S8T2JhMrYM
• http://www.youtube.
com/watch?v=9S_W
waXY1eE
Croup
• Acute inflammation of upper airways causing a
narrowing of the airway. One of the concerns is
epiglottitis which is inflammation of the upper
airway.
• Viral cause
• Produces barky cough or stridor
• Sudden onset, usually at night
• Children usually grows out of this condition
http://www.youtube.com/watch?v=Qbn1Zw5CTbA
RSV
• Respiratory Syncytial
Virus
• Affects the lungs and
respiratory system of
neonates, especially
premature infants
• Highly contagious
• Prevention=hand
washing and
vaccination of at risk
infants
PICC Lines (Vascular Access Device)
• Peripherally inserted central catheter
• Form of IV access or (vascular access
device) that can be used for a
prolonged period of time
• Benefits:
– Medications can burn when
administered and this administration
system avoids that complication.
– Avoid frequent needle sticks for blood.
– Can be used for giving blood and
chemotherapy
• Risks:
-Infection
Lumbar Puncture
• Catheter inserted into
subarachnoid space to
retrieve Cerebrospinal
fluid for testing
• Fluid should be clear and
free from particulate
matter
• Can be mildly
uncomfortable
• Testing for meningitis and
other disorders that aftect
the central nervous
system
Pre Transplant Considerations
• High risk for infection
• Child is very sick and considered unstable
Acute Myeloid Leukemia
Acute Lymphoblastic Leukemia
• ALL & AML start from
immature blood stem cells
(white blood cells) in the
bone marrow and progress
into the blood stream
ultimately affecting lymph
nodes, liver, spleen, ect.
• If not treated quickly, can
be fatal in just a few
months
Solid Organ Tumors
• Tumor is abnormal
growth of cells
• Requires removal of
organ, tumor, chemo,
radiation to treat
Bone Marrow Aspiration/Biopsy
• Painful procedure to
retrieve bone marrow
• Bone marrow is tested for
cancer cells
Common Medications
• Antibodies- given to boost immunity
• Interlukin- given to help boost immunity
• Ketamine- given for sedation
Skills Checklist Review
• Patient and family teaching is integral for a patients
success. Nurses are responsible for preparing a patient
for discharge and home care. The learning process
should start immediately. Nurses are also responsible
for reinforcing pre-op and post-op considerations so
that the patient knows what to expect.
• Recognition of abuse and neglect with appropriate
reporting is important. Nurse are mandatory reporters
and if they fail to report known or suspected abuse
they can be held liable in court for failing to advocate
for the abused child.
Head to Toe Assessment
• Nurses are required to do a head to toe
assessment once per shift. This includes
listening to heart sounds, breath sounds, GI
sounds, checking for edema, and mental
status.
• The nurse should be able to identify
abnormalities based on their assessment and
determine if this is a change from baseline
and reportable to the doctor.
Cardiovascular Assessment
• When assessing the cardiac system, the nurse should
listen to heart sounds, note the rate, and check for
over all circulatory status.
• To check the over all status of a patient the nurse
should look at the patients overall color. (Is the patient
warm dry and pink?)
• Capillary refill is checked by squeezing the tip of a
patient’s finger. When the finger is squeezed the color
will blanch. Within 3 seconds of releasing the squeeze,
the patients finger should turn back to its normal
coloring. If the finger stays blanched longer the 3
seconds there could be a circulatory issue.
Cardiovascular Assessment Disease
Processes
• Cardiopulmonary Arrest- the heart stops beating or is
beating too slow to maintain circulation and “ACLS” must
begin to keep patient alive.
• CHF- Congestive Heart Failure is a condition where the
cardiac muscle is weakened and cannot pump blood
through the body effectively. The blood can back up in the
lower legs and the lungs making it difficulty for a patient to
breath. One of the ways this is treated is to give patient’s
medication that will remove the excess fluid from the
patient’s body that in turn, decreases the workload of the
heart.
• Congenital Heart defects- There are a variety of congenital
heart defects. Congenital means that the condition was
present from birth. Depending on what the defect is will
determine the nursing care.
Cardiac Monitoring
• EKG monitoring- and EKG is a picture of the
electrical activity of the heart. This picture can
tell the cardiologist exactly which part of the
heart is malfunctioning and can diagnose many
different cardiac disorders. Nurses should be
able to differentiate basic deviations from
normal in order to initiate prompt intervention
if necessary.
• Vital Sign Monitoring- I would expect all
applicants to have a 4/4 proficiency in this area.
This is a basic function of nursing and should be
second nature to our applicants.
Pulmonary
• Adventitious Breath Sounds- Are abnormal
lung sounds and can indicate a disease
process such as asthma or CHF.
• Nasal Flaring/Oxygenation Status/Rate
and Work of Breathing- is a condition
present where a child is having difficulty
breathing. In a health child, the diaphragm
moves to assist with breathing. Children
with respiratory conditions often use
other muscles to assist with their
breathing including flaring of the nose and
sternal retractions. Sometimes children
will position themselves “tripod” in a
manner that will help them to breath
more efficiently when their airway is
constricted.
Pulmonary
• Airway Obstruction- If the airway is blocked it
is called obstructed. There are a variety of
causes of airway obstruction including
asthma, aspiration of a foreign body,
anaphylaxis.
Tuberculosis
• A condition caused by inhalation of
a bacteria that causes respiratory
symptoms including cough lasting
longer than 3 weeks, night sweats,
weight loss, and bloody sputum.
• Very contagious and very difficulty
to treat.
• Treatment usually consists of at least
two kinds of antibiotics that have to
be taken religiously for at least 6
months.
• Can cause irreversible lung scarring.
Pulmonary Monitoring
• Pulse Oximetry- a sensor that is put on a finger,
toe, ear, or even the forehead that measures the
amount of oxygen that is circulating in a patients
body.
• Apnea- the absence of breathing. The concern is
if this happens at night the patient could die in
their sleep. Premature babies and those that are
considered high risk are often placed on an apnea
monitor that will alarm if there has been no
inhalations in a specified amount of time.
Neurology
• Glascow Coma Scale- A standardized assessment tool
that measures a patients orientation status. The higher
the score the more alert and awake the person is.
Patients that have lower scores tend to have poorer
outcomes.
• Neurological Assessment- one of the first areas that
declines in a patient is their neurological status.
Children with suspected brain trauma or other issues
require frequent neuro checks to promptly identify
issues. Typically neuro checks are done on all patients
once per shift. If the patient is at risk for neuro injury,
neuro checks can be required every 15 minutes.
Neurological
• Febrile Seizure- Children often present to the
ER after experiencing a febrile seizure. These
are common in children and are preventable
with antipyretic medication such as tylenol
and motrin. There is usually no lasting harm
from one of these events and they are very
different in nature from a true ‘epileptic’
seizure. They can be scary to observe.
Neurological
• Head injury- require neuro
checks to identify decline
• Meningitis- infection and or
inflammation of the
meningies in the brain
causes by bacteria or virus.
Diagnosed via lumbar
puncture. The patient is
usually very sick but usually
recovers without any
deficits if treated
aggressively.
Spina Bifida
• A congenital condition where a
portion of the spine and spinal
nerves grow outside of the patients
spinal canal in a small sac.
• This is completely preventable
through maternal nutrition. Folic
Acid.
• Can cause a varying degree of
disability depending on how many
and how pronounce the protruding
nerves are.
• Some children experience lower
motor function disability and
problems with bowel and bladder
control.
Gastro Intestinal Assessment (GI)
• GI Assessment with bowel sounds- Bowel sounds
should be present when auscultating the abdomen.
The bowel sounds should not be too fast or too slow
and should be the correct pitch. Any deviation from
normal can indicate an abnormal disease process.
• Colostomy Care- should be performed regularly and is
often done by the patient. The patient should be
encouraged to participate in the maintenance and care
of the “stoma” (the bowel opening). The soiled bag is
removed and the skin is cleaned and prepped for
reapplication of the bag “appliance.”
GI Assessment
• Nutritional Status- Can be
determined just by looking at a
patient. Can also be determined by
labs.
• Anorexia is a condition where the
patient refuses to eat an appropriate
amount of calories in the effort to be
in control of their weight. They see
themselves as overweight and have
very low self esteem. They use food
as an environmental factor that they
can control. Considerations for these
patients include psychiatric care to
address underlying body issues.
These patients are at risk for bone
fractures and cardiac arrhythmias
due to their poor nutritional intake.
GI Assessment
• Bulimia- is a condition where the
patient believes that they are over
weight and attempts to influence this
by over eating and then inducing
vomiting or using laxatives to purge the
ingested food. (Binging and purging)
• These patients have underlying
psychological disorders similar to
anorexia and must have therapy as
part of their medical care to correct
underlying psych issues.
• Patients that have bulimia often use
the bathroom immediately after eating
to purge the food they just ingested.
They tend to have esophageal scarring
and often scarring on their hands from
where vomiting has been induced.
They tend to have many dental carries
as the stomach acid from the frequent
vomiting erodes the enamel on their
teeth.
GI Assessment
• Failure to thrive- is a diagnosis
most often given to premature
babies and older adults.
• It means that there is a
nutritional deficit of some
cause, either because of lack of
intake or absorption problems.
• These patients are underweight
and usually appear cachectic.
GI Assessment
• Ingestion/drug overdose- any patient
presenting after ingesting a substance, drug,
or chemical is usually placed on a 51-50 hold
until it is clear that it was accidental and not
intentional.
• Immediately call poison control.
• Charcoal is generally given to absorb the
chemical in the stomach.
GI Assessment
• Liver Failure- the liver is responsible for
processing drugs and detoxifying the body from
harmful substances in addition to producing
enzymes needed for digestion and affecting
clotting times.
• Patients that have liver failure are at risk for
bleeding and can become delirious because of
the build up of toxins in the body.
• The liver often swells and these patients often
look pregnant due to the distended abd.
• The sclera “whites of the eyes” turns a yellow
color.
• The nurse should assess the patients lab work
including LFT’s (Liver Function Tests) that
include various markers for this condition.
These tests include serum ammonia and
amylase.
Genitourinary
• Fluid status of an individual is
assessed by looking at the
mucous membranes and skin
turgor. The most accurate
measurement of hydration
status is blood work.
• When the skin on the back of
a patients hand is pinched, it
should immediately return to
a normal shape and not stay
raised. This is called tenting
and is an indication of
dehydration.
Genitourinary
• Acute/Chronic Renal Failure- condition where the
kidney’s ability to filter blood and control waste
excretion process through urine is impaired.
• Unfiltered toxins and excess water builds up in body
causing stress on various organs including heart.
• Dialysis is required to filter blood when kidneys are
unable. Sometimes kidney transplant is necessary to
promote long term wellness.
• This process of the body self regulating the amount of
water it retains is considered fluid balance.
Genitourinary
• Urinary Tract/Bladder Infection- is a condition
where bacteria, generally from anal area
makes its way into urethra and or bladder. If
untreated can lead to kidney infection.
• Symptoms are painful, frequent urination with
little urine produced. Feeling like bladder is
full even after voiding and having a feeling of
urgency.
• More common in women because urethral
opening is closer to anus than in a man.
• Very common in young children.
• Treatable with antibiotics
• To diagnose, a urine specimen is collected
either by cleaning the perineal area and
voiding into a sterile specimen cup or via
catheter to retrieve urine directly from the
bladder.
Genitourinary
• The measurement of I & O (Intake
and Output)- any fluid that is
ingested or infused into the body is
counted as well as the amount of
urine, surgical drains, emesis
(vomit) ect. that comes out.
• BUN and Creatinine are
measurements of kidney function.
• Serum Electrolytes are used to
measure overall hydration status.
These values include sodium,
potassium, calcium, magnesium. If
they are too high or too low the
plan of care may include giving
supplements or medications to
remove them from the body.
Genitourinary
• Diaper weights- Children in diapers are unable
to void in a collection device. To measure I&O
on these patients, a clean diaper is weighed,
and the soiled diaper is weighed. The
difference is subtracted and converted from
grams to mLs using a conversion tool.
http://calculator-
converter.com/converter_g_to_ml_grams_to_
milliliters_calculator.php
Endocrine Assessment
• Diabetes- is a condition where the body attempts to
neutralize the amount of sugar that is circulating in the
body at a given time.
• People who are diabetic lack the ability to produce their
own insulin or fail to produce enough insulin and must have
this supplemented via injections.
• Sugar in the blood can cause devastating effects on the
human body. It can delay healing or wounds and can harm
the kidneys and eyes. People with diabetes have loss of
sensation in their feet and often have wounds that they are
unaware of simply because they cannot feel them.
• Diabetes symptoms are managed through diet and
medication. This is not a condition that can be cured.
Endocrine
• Diabetic Ketoacidosis is a condition where the
blood sugar is extremely high. This alters the
patients body chemistry in a way where there
is break down of healthy tissues. This can lead
to death if not treated.
• Can occur in children that have not yet been
diagnosed with diabetes.
• Blood sugar can be checked by a finger stick or
from serum electrolyte lab work.
Endocrine
• Circulation checks are
performed by checking the
pulse in the affected limb.
Part of this assessment can
also include capillary refill
check. (see previous
cardiovascular slide.)
• Sometimes the pulse is
marked with an X so that it
can easily be found a
second time by the primary
nurse and/or other health
care workers
Musculoskeletal
• Muscular Dystrophy- a
condition where all of the
muscles in the body are
weakened including the
heart and respiratory
muscles.
• There is no cure
Musculoskeletal
• Cast Care- Casts cannot get wet and must be covered
with plastic when showering. Even excessive sweating
can be enough moisture to cause mildew, mold or
other infections to cause harm to the covered skin.
• You should never use an object to scratch underneath
the cast.
• It is important to keep the cast elevated to keep
swelling at a minimum.
• If there was a great decrease in the amount of swelling
under the cast, and it is now rubbing against the skin,
the patient may need a new cast applied that fits more
appropriately.
Crutch Walking
• It is important that the crutches are fitted
specifically for the patient.
• The patient should not rest arm pits on the
top of the crutches. Doing so can damage the
brachial nerves. The patient should use their
arm strength to avoid leaning too heavily on
the crutches.
• http://www.youtube.com/watch?v=pYzUQb79
_Rw
Spica Cast
• A spica cast (also called a hip
spica cast or body cast)
immobilizes the hips and
thighs so that bones or
tendons can heal properly.
It's usually put on in surgery
while the child is sleeping.
• There are several types of
spica casts. They begin at the
chest and may extend down
to cover one leg, both legs,
or the leg on one side and
down to the hip or knee of
the other side. The doctor
will decide what type of spica
cast your child needs.
Blood Transfusions
• Require two licensed
caregivers verify that
the appropriate blood is
given to the appropriate
patient.
• High risk for reaction to
the blood that increases
with each transfusion.
Chronically ill patients
that have had multiple
transfusions in the past
are at the highest risk
for complication.
Hemophilia
• Patient lacks a clotting factor
in their blood that causes
them to be unable to stop
bleeding.
• Varying degrees of severity.
• Concern for internal injuries
because blood is not
apparently visualized as with
an open wound.
• Clotting factor replaced
intravenously.
• Genetic in origin, no cure,
mostly in boys, very very very
rare in females
HIV/AIDS
• Patient has no/ weakend
immune system to respond to
infections.
• As a result, patients can contract
rare conditions that are
extremely rare in health
individuals.
• Reverse isolation precautions-
where healthcare workers wear
gowns and masks to avoid
infecting the patient rather than
wearing the protective
equipment for fear that patient
will infect them.
• High incidence of cancer,
tuberculosis, pneumonia.
Anaphylactic Shock
• Condition in which patient’s immune
response is triggered causing a swelling
of the airway, sharp drop in blood
pressure and hives with itching.
• The concern in these patients is that
the airway will close and the patient
will not be able to breathe.
• Generally, anaphylaxis doesn’t happen
on the first exposure to the allergen
but rather on subsequent exposures.
(The patient may have been on
lisinopril for 10 years but present with
angioedema (swelling) after taking a
regularly scheduled dose.)
• Common causes of anaphylaxis in
children are:
– Peanuts
– Bee Stings
– Penicillin
– Eggs
– Honey
Wound/Integumentary Assessment
• Signs and symptoms of
infection:
– Redness
– Green/yellowish drainage
– Pain and swelling
– Foul odor
Assessment of Burns
• Very painful!!!
• High risk of infection
• Must have tissue cleaned
out to avoid scarring that
will limit mobility after the
wound has healed.
Bladder Irrigation
• Bladder is irrigated with normal
saline to remove blood clots after
bladder surgery.
• I have only performed this
procedure on older men that have
prostate issues or have had recent
bladder surgery. I briefly
researched this procedure in
children and did not readily find
explanation.
Medication Delivery
A. IM Medications- Given
intramuscularly in approve sites
depending on the medication.
Allows for slower absorption of the
drug. Ex. Vaccinations, antibiotics,
pain medication.
B. SQ- Subcutaneous is just under the
skin in fatty areas including abd,
inner thigh and back of arm. Ex.
Insulin.
C. NG- Nasogastric tube- for patients
that are unable to swallow
medications on their own. This
tube is inserted in the nose and
extends down to the stomach.
• NG tube insertion is confirmed
with chest x-ray, instillation of air
while listening to stomach, and
aspiration of gastric contents.
C
C
B
A
Medication Delivery
• PO- is Latin for by mouth
A. Rectal Medications-
“suppositories” for
patients that are vomiting
and have no IV access.
B & C. Needleless systems-
RMCSJ is a needleless
system. Medications come
in a variety of packaging. A
needle or other device is
required to draw up the
medication from the vial
and into the delivery
syringe (C). Figure B is a
lure lock syringe that can
be twisted on to a hub.
A
C
B
IV Therapy
• An arm board is used in
pediatric and sometimes
adult settings to maintain and
IV.
• Tape or gauze is often applied
to secure the IV in place and
ensure that it doesn’t
intentionally or inadvertently
get pulled out.
Adverse Reactions
• Can occur if the medication is delivered
outside of the vein
• Medication can be caustic to the vein
• If IV was misplaced, it should be reinserted
• If medication is caustic to vein, nurse can
slow infusion down or use warm compress
over site to ease pain of administration.
• Some medications are extremely toxic and
if they do not go directly into vein and get
into the surrounding tissue, complications
and skin death can occur. (VERY RARE)
• Common symptoms can include:
– Pain
– Redness
– Swelling
– Warm or cold area around IV site
IV Equipment
A. Heparin or Saline Lock
B. Infusion Pump- Generally used for children
and adults. The machine is programmed to
deliver the appropriate rate/dosage of
medication.
C. Syringe pump- used for infants and children
that only need a small amount or more
concentrated medication delivered. Syringe
with medication is attached directly to
tubing and placed in the machine rather
than a full bag of medication or fluid.
D. PCA pump- Patient controlled analgesia,
locked medication delivery system with a
button that the patient can press when
they feel like they need additional pain
medication. The frequency and dosage is
programmed into the machine to avoid
over dosage. The idea behind the self
administration is that pain can be
controlled via the patient and that the
lowest amount of medication is delivered
as possible to maintain comfort.
A
B
C
D
Scalp Vein
• Difficult to insert a peripheral line
in children due to small veins and
lost of subcutaneous fat.
• Scalp vein is a good choice
because of its close proximity to
the surface, minimal
subcutaneous fat and less
movement and the lack of a
flexible joint
• This reduces the likelihood of
dislodging the catheter, which is
common with intravenous
catheters placed in the arms or
legs.
Intraosseous Infusion
• IO infusion- Catheter inserted into bone.
• Usually inserted during emergency situations
when there is no IV access available.
Oxygen Delivery Devices
A. Ambu-bag
B. Nasal Cannula
C. Non-Rebreather Mask
D. Portable Oxygen
E. Venti Mask
A
B
C
D
E
Oxygen Administration
• Nebulizer Treatments-Broncho-dilator such as
Albuterol is nebulized and inhaled to open air
ways and assist with breathing.
• Tracheostomy- Surgical opening of airway if
throat is closed due to inflammation or foreign
body blockage. Some patients have trachs for
life due to anatomical considerations.
Assisted Airway
• Intubation-Process
of inserting a tube
into a patient’s
airway to assist with
breathing. Usually
inserted in the field
or ER.
• Extubation- Process
of removing the
tube that has been
assisting with
breathing. Usually
removed in the ICU.
Isolette
• Isolette- to keep infants at
the appropriate
temperature, protected from
infection, and to provide
photo therapy. Used in NICU.
• Phototherapy- used to break
up excess bilirubin that
collects in the premature
infants body. Eyes must be
shielded to prevent damage
to retina.
PEG Tube
• Tube that is surgically inserted into through
abdominal wall into stomach to give nutrition
and medications to. This is a more long term
solution than an NG tube. Given to patients
that are unable to swallow or in a vegetative
state ect.
Nutritional Therapy
• TPN and Hyperalimentation- Total nutrition
given via IV though PICC or Central Line
• Tube Feeding Pumps- Special pump used
for PEG tube feedings. Generally, patients
have continuous feedings 24 hours a day to
maintain nutritional status and blood sugar
levels.
• When a patient is received tube feedings,
the head of the bed should not be lower
than 30 degrees to avoid the possibility of
aspiration
Pain Management
• Moderate sedation for procedures such as:
– Bone dislocation or fracture
• Ramsey Scale- Standardized scoring tool that
rates level of sedation
• Chest Physiotherapy- to assist with the
clearing of secretions for cystic fibrosis
children.
http://www.youtube.com/watch?v=B8wTlqhu
Spc
Chest Tube
• Chest Tube Drainage System- generally chest
tubes are inserted in the ER after chest trauma
from MVC or other accident due to a
collapsed lung.
• Nurses must assess the amount of drainage
that collects during their shift and maintain
the sterility of the collection unit.
Other Equipment
• Doppler- Used to check
blood flow in an
extremity. Also used to
detect a heart beat in a
pregnant mother who
is greater than 20
weeks gestation.
• Hyper/Hypothermia
Blanket- used to cool
or heat a patient who’s
temperature is far
outside normal limits.
The End
• Questions

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Pediatric Term Review

  • 2. Cystic Fibrosis • Chronically ill children with respiratory issues -Frequent chronic infections • Thick mucous secretions • Absorption issues • Shortened life expectancy- America 37.4 years • Anglosaxon children • Need lung transplant
  • 3. Cerebral Palsey • Caused by damage to motor control center of the brain while it is developing • Causes motor issues, visual impairments • No cure • High prevalence of epilepsy • Lifetime of physical therapy to maintain optimal function
  • 4. Sickle Cell Anemia • Genetic adaptation to malaria • Primarily affects African American’s • Affected children have episodes of severe pain • Require surgery to insert port and often remove spleen • These children are very sick and in a lot of pain
  • 5. Crohns Disease • Inflammatory disorder affecting entire GI tract • Abd pain • Bloody stool • Trouble with nutrition • Often require colostomy
  • 6. Crohn’s Disease • Bowel is attached to abdominal wall creating a “stoma” so that feces can pass freely into a collection bag
  • 7. Asthma • Chronic inflammatory disease causing a narrowing of the lower airways • This narrowing causes wheezing or whistling sound • http://www.youtube. com/watch?v=- S8T2JhMrYM • http://www.youtube. com/watch?v=9S_W waXY1eE
  • 8. Croup • Acute inflammation of upper airways causing a narrowing of the airway. One of the concerns is epiglottitis which is inflammation of the upper airway. • Viral cause • Produces barky cough or stridor • Sudden onset, usually at night • Children usually grows out of this condition http://www.youtube.com/watch?v=Qbn1Zw5CTbA
  • 9. RSV • Respiratory Syncytial Virus • Affects the lungs and respiratory system of neonates, especially premature infants • Highly contagious • Prevention=hand washing and vaccination of at risk infants
  • 10. PICC Lines (Vascular Access Device) • Peripherally inserted central catheter • Form of IV access or (vascular access device) that can be used for a prolonged period of time • Benefits: – Medications can burn when administered and this administration system avoids that complication. – Avoid frequent needle sticks for blood. – Can be used for giving blood and chemotherapy • Risks: -Infection
  • 11. Lumbar Puncture • Catheter inserted into subarachnoid space to retrieve Cerebrospinal fluid for testing • Fluid should be clear and free from particulate matter • Can be mildly uncomfortable • Testing for meningitis and other disorders that aftect the central nervous system
  • 12. Pre Transplant Considerations • High risk for infection • Child is very sick and considered unstable
  • 13. Acute Myeloid Leukemia Acute Lymphoblastic Leukemia • ALL & AML start from immature blood stem cells (white blood cells) in the bone marrow and progress into the blood stream ultimately affecting lymph nodes, liver, spleen, ect. • If not treated quickly, can be fatal in just a few months
  • 14. Solid Organ Tumors • Tumor is abnormal growth of cells • Requires removal of organ, tumor, chemo, radiation to treat
  • 15. Bone Marrow Aspiration/Biopsy • Painful procedure to retrieve bone marrow • Bone marrow is tested for cancer cells
  • 16. Common Medications • Antibodies- given to boost immunity • Interlukin- given to help boost immunity • Ketamine- given for sedation
  • 17. Skills Checklist Review • Patient and family teaching is integral for a patients success. Nurses are responsible for preparing a patient for discharge and home care. The learning process should start immediately. Nurses are also responsible for reinforcing pre-op and post-op considerations so that the patient knows what to expect. • Recognition of abuse and neglect with appropriate reporting is important. Nurse are mandatory reporters and if they fail to report known or suspected abuse they can be held liable in court for failing to advocate for the abused child.
  • 18. Head to Toe Assessment • Nurses are required to do a head to toe assessment once per shift. This includes listening to heart sounds, breath sounds, GI sounds, checking for edema, and mental status. • The nurse should be able to identify abnormalities based on their assessment and determine if this is a change from baseline and reportable to the doctor.
  • 19. Cardiovascular Assessment • When assessing the cardiac system, the nurse should listen to heart sounds, note the rate, and check for over all circulatory status. • To check the over all status of a patient the nurse should look at the patients overall color. (Is the patient warm dry and pink?) • Capillary refill is checked by squeezing the tip of a patient’s finger. When the finger is squeezed the color will blanch. Within 3 seconds of releasing the squeeze, the patients finger should turn back to its normal coloring. If the finger stays blanched longer the 3 seconds there could be a circulatory issue.
  • 20. Cardiovascular Assessment Disease Processes • Cardiopulmonary Arrest- the heart stops beating or is beating too slow to maintain circulation and “ACLS” must begin to keep patient alive. • CHF- Congestive Heart Failure is a condition where the cardiac muscle is weakened and cannot pump blood through the body effectively. The blood can back up in the lower legs and the lungs making it difficulty for a patient to breath. One of the ways this is treated is to give patient’s medication that will remove the excess fluid from the patient’s body that in turn, decreases the workload of the heart. • Congenital Heart defects- There are a variety of congenital heart defects. Congenital means that the condition was present from birth. Depending on what the defect is will determine the nursing care.
  • 21. Cardiac Monitoring • EKG monitoring- and EKG is a picture of the electrical activity of the heart. This picture can tell the cardiologist exactly which part of the heart is malfunctioning and can diagnose many different cardiac disorders. Nurses should be able to differentiate basic deviations from normal in order to initiate prompt intervention if necessary. • Vital Sign Monitoring- I would expect all applicants to have a 4/4 proficiency in this area. This is a basic function of nursing and should be second nature to our applicants.
  • 22. Pulmonary • Adventitious Breath Sounds- Are abnormal lung sounds and can indicate a disease process such as asthma or CHF. • Nasal Flaring/Oxygenation Status/Rate and Work of Breathing- is a condition present where a child is having difficulty breathing. In a health child, the diaphragm moves to assist with breathing. Children with respiratory conditions often use other muscles to assist with their breathing including flaring of the nose and sternal retractions. Sometimes children will position themselves “tripod” in a manner that will help them to breath more efficiently when their airway is constricted.
  • 23. Pulmonary • Airway Obstruction- If the airway is blocked it is called obstructed. There are a variety of causes of airway obstruction including asthma, aspiration of a foreign body, anaphylaxis.
  • 24. Tuberculosis • A condition caused by inhalation of a bacteria that causes respiratory symptoms including cough lasting longer than 3 weeks, night sweats, weight loss, and bloody sputum. • Very contagious and very difficulty to treat. • Treatment usually consists of at least two kinds of antibiotics that have to be taken religiously for at least 6 months. • Can cause irreversible lung scarring.
  • 25. Pulmonary Monitoring • Pulse Oximetry- a sensor that is put on a finger, toe, ear, or even the forehead that measures the amount of oxygen that is circulating in a patients body. • Apnea- the absence of breathing. The concern is if this happens at night the patient could die in their sleep. Premature babies and those that are considered high risk are often placed on an apnea monitor that will alarm if there has been no inhalations in a specified amount of time.
  • 26. Neurology • Glascow Coma Scale- A standardized assessment tool that measures a patients orientation status. The higher the score the more alert and awake the person is. Patients that have lower scores tend to have poorer outcomes. • Neurological Assessment- one of the first areas that declines in a patient is their neurological status. Children with suspected brain trauma or other issues require frequent neuro checks to promptly identify issues. Typically neuro checks are done on all patients once per shift. If the patient is at risk for neuro injury, neuro checks can be required every 15 minutes.
  • 27. Neurological • Febrile Seizure- Children often present to the ER after experiencing a febrile seizure. These are common in children and are preventable with antipyretic medication such as tylenol and motrin. There is usually no lasting harm from one of these events and they are very different in nature from a true ‘epileptic’ seizure. They can be scary to observe.
  • 28. Neurological • Head injury- require neuro checks to identify decline • Meningitis- infection and or inflammation of the meningies in the brain causes by bacteria or virus. Diagnosed via lumbar puncture. The patient is usually very sick but usually recovers without any deficits if treated aggressively.
  • 29. Spina Bifida • A congenital condition where a portion of the spine and spinal nerves grow outside of the patients spinal canal in a small sac. • This is completely preventable through maternal nutrition. Folic Acid. • Can cause a varying degree of disability depending on how many and how pronounce the protruding nerves are. • Some children experience lower motor function disability and problems with bowel and bladder control.
  • 30. Gastro Intestinal Assessment (GI) • GI Assessment with bowel sounds- Bowel sounds should be present when auscultating the abdomen. The bowel sounds should not be too fast or too slow and should be the correct pitch. Any deviation from normal can indicate an abnormal disease process. • Colostomy Care- should be performed regularly and is often done by the patient. The patient should be encouraged to participate in the maintenance and care of the “stoma” (the bowel opening). The soiled bag is removed and the skin is cleaned and prepped for reapplication of the bag “appliance.”
  • 31. GI Assessment • Nutritional Status- Can be determined just by looking at a patient. Can also be determined by labs. • Anorexia is a condition where the patient refuses to eat an appropriate amount of calories in the effort to be in control of their weight. They see themselves as overweight and have very low self esteem. They use food as an environmental factor that they can control. Considerations for these patients include psychiatric care to address underlying body issues. These patients are at risk for bone fractures and cardiac arrhythmias due to their poor nutritional intake.
  • 32. GI Assessment • Bulimia- is a condition where the patient believes that they are over weight and attempts to influence this by over eating and then inducing vomiting or using laxatives to purge the ingested food. (Binging and purging) • These patients have underlying psychological disorders similar to anorexia and must have therapy as part of their medical care to correct underlying psych issues. • Patients that have bulimia often use the bathroom immediately after eating to purge the food they just ingested. They tend to have esophageal scarring and often scarring on their hands from where vomiting has been induced. They tend to have many dental carries as the stomach acid from the frequent vomiting erodes the enamel on their teeth.
  • 33. GI Assessment • Failure to thrive- is a diagnosis most often given to premature babies and older adults. • It means that there is a nutritional deficit of some cause, either because of lack of intake or absorption problems. • These patients are underweight and usually appear cachectic.
  • 34. GI Assessment • Ingestion/drug overdose- any patient presenting after ingesting a substance, drug, or chemical is usually placed on a 51-50 hold until it is clear that it was accidental and not intentional. • Immediately call poison control. • Charcoal is generally given to absorb the chemical in the stomach.
  • 35. GI Assessment • Liver Failure- the liver is responsible for processing drugs and detoxifying the body from harmful substances in addition to producing enzymes needed for digestion and affecting clotting times. • Patients that have liver failure are at risk for bleeding and can become delirious because of the build up of toxins in the body. • The liver often swells and these patients often look pregnant due to the distended abd. • The sclera “whites of the eyes” turns a yellow color. • The nurse should assess the patients lab work including LFT’s (Liver Function Tests) that include various markers for this condition. These tests include serum ammonia and amylase.
  • 36. Genitourinary • Fluid status of an individual is assessed by looking at the mucous membranes and skin turgor. The most accurate measurement of hydration status is blood work. • When the skin on the back of a patients hand is pinched, it should immediately return to a normal shape and not stay raised. This is called tenting and is an indication of dehydration.
  • 37. Genitourinary • Acute/Chronic Renal Failure- condition where the kidney’s ability to filter blood and control waste excretion process through urine is impaired. • Unfiltered toxins and excess water builds up in body causing stress on various organs including heart. • Dialysis is required to filter blood when kidneys are unable. Sometimes kidney transplant is necessary to promote long term wellness. • This process of the body self regulating the amount of water it retains is considered fluid balance.
  • 38. Genitourinary • Urinary Tract/Bladder Infection- is a condition where bacteria, generally from anal area makes its way into urethra and or bladder. If untreated can lead to kidney infection. • Symptoms are painful, frequent urination with little urine produced. Feeling like bladder is full even after voiding and having a feeling of urgency. • More common in women because urethral opening is closer to anus than in a man. • Very common in young children. • Treatable with antibiotics • To diagnose, a urine specimen is collected either by cleaning the perineal area and voiding into a sterile specimen cup or via catheter to retrieve urine directly from the bladder.
  • 39. Genitourinary • The measurement of I & O (Intake and Output)- any fluid that is ingested or infused into the body is counted as well as the amount of urine, surgical drains, emesis (vomit) ect. that comes out. • BUN and Creatinine are measurements of kidney function. • Serum Electrolytes are used to measure overall hydration status. These values include sodium, potassium, calcium, magnesium. If they are too high or too low the plan of care may include giving supplements or medications to remove them from the body.
  • 40. Genitourinary • Diaper weights- Children in diapers are unable to void in a collection device. To measure I&O on these patients, a clean diaper is weighed, and the soiled diaper is weighed. The difference is subtracted and converted from grams to mLs using a conversion tool. http://calculator- converter.com/converter_g_to_ml_grams_to_ milliliters_calculator.php
  • 41. Endocrine Assessment • Diabetes- is a condition where the body attempts to neutralize the amount of sugar that is circulating in the body at a given time. • People who are diabetic lack the ability to produce their own insulin or fail to produce enough insulin and must have this supplemented via injections. • Sugar in the blood can cause devastating effects on the human body. It can delay healing or wounds and can harm the kidneys and eyes. People with diabetes have loss of sensation in their feet and often have wounds that they are unaware of simply because they cannot feel them. • Diabetes symptoms are managed through diet and medication. This is not a condition that can be cured.
  • 42. Endocrine • Diabetic Ketoacidosis is a condition where the blood sugar is extremely high. This alters the patients body chemistry in a way where there is break down of healthy tissues. This can lead to death if not treated. • Can occur in children that have not yet been diagnosed with diabetes. • Blood sugar can be checked by a finger stick or from serum electrolyte lab work.
  • 43. Endocrine • Circulation checks are performed by checking the pulse in the affected limb. Part of this assessment can also include capillary refill check. (see previous cardiovascular slide.) • Sometimes the pulse is marked with an X so that it can easily be found a second time by the primary nurse and/or other health care workers
  • 44. Musculoskeletal • Muscular Dystrophy- a condition where all of the muscles in the body are weakened including the heart and respiratory muscles. • There is no cure
  • 45. Musculoskeletal • Cast Care- Casts cannot get wet and must be covered with plastic when showering. Even excessive sweating can be enough moisture to cause mildew, mold or other infections to cause harm to the covered skin. • You should never use an object to scratch underneath the cast. • It is important to keep the cast elevated to keep swelling at a minimum. • If there was a great decrease in the amount of swelling under the cast, and it is now rubbing against the skin, the patient may need a new cast applied that fits more appropriately.
  • 46. Crutch Walking • It is important that the crutches are fitted specifically for the patient. • The patient should not rest arm pits on the top of the crutches. Doing so can damage the brachial nerves. The patient should use their arm strength to avoid leaning too heavily on the crutches. • http://www.youtube.com/watch?v=pYzUQb79 _Rw
  • 47. Spica Cast • A spica cast (also called a hip spica cast or body cast) immobilizes the hips and thighs so that bones or tendons can heal properly. It's usually put on in surgery while the child is sleeping. • There are several types of spica casts. They begin at the chest and may extend down to cover one leg, both legs, or the leg on one side and down to the hip or knee of the other side. The doctor will decide what type of spica cast your child needs.
  • 48. Blood Transfusions • Require two licensed caregivers verify that the appropriate blood is given to the appropriate patient. • High risk for reaction to the blood that increases with each transfusion. Chronically ill patients that have had multiple transfusions in the past are at the highest risk for complication.
  • 49. Hemophilia • Patient lacks a clotting factor in their blood that causes them to be unable to stop bleeding. • Varying degrees of severity. • Concern for internal injuries because blood is not apparently visualized as with an open wound. • Clotting factor replaced intravenously. • Genetic in origin, no cure, mostly in boys, very very very rare in females
  • 50. HIV/AIDS • Patient has no/ weakend immune system to respond to infections. • As a result, patients can contract rare conditions that are extremely rare in health individuals. • Reverse isolation precautions- where healthcare workers wear gowns and masks to avoid infecting the patient rather than wearing the protective equipment for fear that patient will infect them. • High incidence of cancer, tuberculosis, pneumonia.
  • 51. Anaphylactic Shock • Condition in which patient’s immune response is triggered causing a swelling of the airway, sharp drop in blood pressure and hives with itching. • The concern in these patients is that the airway will close and the patient will not be able to breathe. • Generally, anaphylaxis doesn’t happen on the first exposure to the allergen but rather on subsequent exposures. (The patient may have been on lisinopril for 10 years but present with angioedema (swelling) after taking a regularly scheduled dose.) • Common causes of anaphylaxis in children are: – Peanuts – Bee Stings – Penicillin – Eggs – Honey
  • 52. Wound/Integumentary Assessment • Signs and symptoms of infection: – Redness – Green/yellowish drainage – Pain and swelling – Foul odor
  • 53. Assessment of Burns • Very painful!!! • High risk of infection • Must have tissue cleaned out to avoid scarring that will limit mobility after the wound has healed.
  • 54. Bladder Irrigation • Bladder is irrigated with normal saline to remove blood clots after bladder surgery. • I have only performed this procedure on older men that have prostate issues or have had recent bladder surgery. I briefly researched this procedure in children and did not readily find explanation.
  • 55. Medication Delivery A. IM Medications- Given intramuscularly in approve sites depending on the medication. Allows for slower absorption of the drug. Ex. Vaccinations, antibiotics, pain medication. B. SQ- Subcutaneous is just under the skin in fatty areas including abd, inner thigh and back of arm. Ex. Insulin. C. NG- Nasogastric tube- for patients that are unable to swallow medications on their own. This tube is inserted in the nose and extends down to the stomach. • NG tube insertion is confirmed with chest x-ray, instillation of air while listening to stomach, and aspiration of gastric contents. C C B A
  • 56. Medication Delivery • PO- is Latin for by mouth A. Rectal Medications- “suppositories” for patients that are vomiting and have no IV access. B & C. Needleless systems- RMCSJ is a needleless system. Medications come in a variety of packaging. A needle or other device is required to draw up the medication from the vial and into the delivery syringe (C). Figure B is a lure lock syringe that can be twisted on to a hub. A C B
  • 57. IV Therapy • An arm board is used in pediatric and sometimes adult settings to maintain and IV. • Tape or gauze is often applied to secure the IV in place and ensure that it doesn’t intentionally or inadvertently get pulled out.
  • 58. Adverse Reactions • Can occur if the medication is delivered outside of the vein • Medication can be caustic to the vein • If IV was misplaced, it should be reinserted • If medication is caustic to vein, nurse can slow infusion down or use warm compress over site to ease pain of administration. • Some medications are extremely toxic and if they do not go directly into vein and get into the surrounding tissue, complications and skin death can occur. (VERY RARE) • Common symptoms can include: – Pain – Redness – Swelling – Warm or cold area around IV site
  • 59. IV Equipment A. Heparin or Saline Lock B. Infusion Pump- Generally used for children and adults. The machine is programmed to deliver the appropriate rate/dosage of medication. C. Syringe pump- used for infants and children that only need a small amount or more concentrated medication delivered. Syringe with medication is attached directly to tubing and placed in the machine rather than a full bag of medication or fluid. D. PCA pump- Patient controlled analgesia, locked medication delivery system with a button that the patient can press when they feel like they need additional pain medication. The frequency and dosage is programmed into the machine to avoid over dosage. The idea behind the self administration is that pain can be controlled via the patient and that the lowest amount of medication is delivered as possible to maintain comfort. A B C D
  • 60. Scalp Vein • Difficult to insert a peripheral line in children due to small veins and lost of subcutaneous fat. • Scalp vein is a good choice because of its close proximity to the surface, minimal subcutaneous fat and less movement and the lack of a flexible joint • This reduces the likelihood of dislodging the catheter, which is common with intravenous catheters placed in the arms or legs.
  • 61. Intraosseous Infusion • IO infusion- Catheter inserted into bone. • Usually inserted during emergency situations when there is no IV access available.
  • 62. Oxygen Delivery Devices A. Ambu-bag B. Nasal Cannula C. Non-Rebreather Mask D. Portable Oxygen E. Venti Mask A B C D E
  • 63. Oxygen Administration • Nebulizer Treatments-Broncho-dilator such as Albuterol is nebulized and inhaled to open air ways and assist with breathing. • Tracheostomy- Surgical opening of airway if throat is closed due to inflammation or foreign body blockage. Some patients have trachs for life due to anatomical considerations.
  • 64. Assisted Airway • Intubation-Process of inserting a tube into a patient’s airway to assist with breathing. Usually inserted in the field or ER. • Extubation- Process of removing the tube that has been assisting with breathing. Usually removed in the ICU.
  • 65. Isolette • Isolette- to keep infants at the appropriate temperature, protected from infection, and to provide photo therapy. Used in NICU. • Phototherapy- used to break up excess bilirubin that collects in the premature infants body. Eyes must be shielded to prevent damage to retina.
  • 66. PEG Tube • Tube that is surgically inserted into through abdominal wall into stomach to give nutrition and medications to. This is a more long term solution than an NG tube. Given to patients that are unable to swallow or in a vegetative state ect.
  • 67. Nutritional Therapy • TPN and Hyperalimentation- Total nutrition given via IV though PICC or Central Line • Tube Feeding Pumps- Special pump used for PEG tube feedings. Generally, patients have continuous feedings 24 hours a day to maintain nutritional status and blood sugar levels. • When a patient is received tube feedings, the head of the bed should not be lower than 30 degrees to avoid the possibility of aspiration
  • 68. Pain Management • Moderate sedation for procedures such as: – Bone dislocation or fracture • Ramsey Scale- Standardized scoring tool that rates level of sedation
  • 69. • Chest Physiotherapy- to assist with the clearing of secretions for cystic fibrosis children. http://www.youtube.com/watch?v=B8wTlqhu Spc
  • 70. Chest Tube • Chest Tube Drainage System- generally chest tubes are inserted in the ER after chest trauma from MVC or other accident due to a collapsed lung. • Nurses must assess the amount of drainage that collects during their shift and maintain the sterility of the collection unit.
  • 71. Other Equipment • Doppler- Used to check blood flow in an extremity. Also used to detect a heart beat in a pregnant mother who is greater than 20 weeks gestation. • Hyper/Hypothermia Blanket- used to cool or heat a patient who’s temperature is far outside normal limits.