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Study Guide EXAM #2- Pediatrics EXAM is on CHPT 6, 8, 9 & 14 Slides and Book Chapter When conducting a pediatric assessment, know the distinguishing “oral eruptions” associated with: (Ch.6) Rubeola/Measles → red eruptions w/white center on buccal mucosa = Koplik spots (tiny gray white specks surrounded by red halos; noted on buccal mucosa opposite to molars about 2 days before rash appears) ★ Sx: fever, malaise, lethargy, Koplik spots ★ Tx: symptoms ★ Precautions: droplet Chicken pox/Varicella → Sores in mouth lasting about a day & can turn into ulcers that are yellow/gray in color
Roseola Infantum → Erythematous macules on the soft palate aka Nagayama spots → Sudden/high fever followed by rash that begins on trunk & spreads to neck, face, arms & legs caused by human herpes virus 6. Tx fever to prevent seizures, fluids/electrolytes, rule out other causes of fever like ear infection. Rubella/German Measles → 3 day measles; distinctive maculopapular rash Sx: prodromal sx (fever, sore throat, HA, lymphadenopathy) followed by rash Forcheimer spots with rash (small, red, painless red spots/petechial macules on soft palate; back of roof of mouth & throat) Presence of lymphadenopathy helps differentiate rubella from other rash illnesses Complications: intrauterine death in fetal infections MMR vaccine: 12-15 mos & second dose 4-6 years Can be sore & itchy
lesions are crusted they are no longer infectious (may be 1 week after onset). Lasts about 2 weeks. Prevention ↠ Vaccine at 12-15 mos with a booster between 4-6 years of age. ★ VCZ immune globin (VariZIG) is given to high-risk children to prevent development of varicella after exposure. Understand 5 th^ disease: Symptoms ★ rose colored eruptions starting at cheeks “slapped cheek” or “Lacy” appearance ★ low grade fever, HA, upper respiratory infection ★ Macular rash spreading rapidly to trunk and proximal extremities (not present in palms or soles) Causes ↪ human parvovirus B Treatment ★ Supportive care, no tx or vaccine ★ No need for isolation because once rash appears, child is not contagious Contraindications/Effects of the disease ★ Not appropriate to assign to a nurse who is pregnant ie. 3 year old with 5th dx receiving supportive care w/tylenol. ★ If pregnant women get 5th dx, fetal death can happen! Understand Lyme disease:
Etiology: Most common vector-borne disease (late spring/summer) transmitted by infected deer tick. Causes infectious blood-borne bacterial disease (Bacterium: Borrelia Burgdorferi). Ticks must feed for 36-72 hrs typically for transmission to occur. Diagnosis: ★ Fever/Chills ★ Fatigue ★ HA ★ Muscle aches & swollen lymph nodes ★ Erythema Migrans: Bullseye, circular rash, not itchy/painful, typically gets bigger over several days ★ Some people don’t exhibit this rash; ○ 2 step process: Blood work for antibodies AGAINST Lyme disease can be taken if others symptoms are present & ELISA test. (If ELISA negative, no further testing is needed, if ELISA & western blot test is positive then the patient has lime dx) ★ If untreated, Lyme disease can spread to the heart, joints, and nervous system: ○ Severe HA/neck stiffness ○ Arthritis (severe joint pain/swelling) ○ Facial palsy (drooping of face) ○ Meningitis ○ Heart palpitations ○ Dizziness, SOB ○ Nerve pain (numbness/tingling in hands and feet) Treatment: ★ Antibiotics ○ amoxicillin/doxycycline children >8 years ○ amoxicillin & cefuroxime (Ceftin) if <8 years old ○ S/E of doxy = discoloration of teeth ★ Small % can have pain and fatigue >6 mos (post-treatment lyme dx syndrome)
★ Complications include ascending paralysis w/sx like: GBS, CNS damage. Membranous lesions in tonsils can spread leading to airway obstruction Treatment & care ★ Antibiotics; test for allergy to horse serum before giving Antitoxin. Drug of choice is usually penicillin G or erythromycin if allergic to penicillin ★ Treat close contacts prophylactically ★ Preventable with immunization; vaccine good for 10 years (boosters) ★ Contact and droplet precautions, Maintain airway! Immunization regime ↳ (Ch.6, slide 8) ★ DTaP vaccine 0.5ml IM is given at 2mos, 4mos, 6mos, 15-18 mos, and 4-6 years for a total of 5 doses. ★ Tdap given as booster at 1 1-12 years (PNIE p.177) ★ Tetanus & Diphtheria (Td boosters) given at 10-year intervals (especially important for adults to receive to avoid giving to babies) ★ Do not give DTaP vaccine to children with a CNS problem (cerebral palsy ok), or live vaccines to pregnant immune deficiency dx or those receiving immunosuppressive therapy, or anaphylaxis/allergy. *Side note (not on guide): → Tetanus: acute exotoxin-mediated infection ● Sx: muscle rigidity, body spasms, lockjaw, stiff neck, and dysphagia. ● Transmitted through penetrating wounds; burns, contaminated soil, dust, animal feces, and surgical instruments (babies born in dirty areas; third world countries). ● Affects nerve axons causing involuntary muscle contractions, rigidity & seizures. ● Diagnosed by hx & sx. ● Tx includes tetanus immune globulin (neutralizes toxin); toxoid injection, penicillin G abx IV, muscle relaxants/sedatives. ● Tetanus injections given every 10 years, or with dirty wounds, if immunization is unknown or >5 years since the last vaccine. Maintain airway, avoid stimulation. Understand Tuberculin Testing, Tuberculous and who this test should be administered to. Transmission Airborne (droplet precautions); infection of lungs by mycobacterium causing granulomas/lesions in lungs. S/S:
❖ Cough >3 weeks ❖ Purulent bloody sputum ❖ Unexplained weight loss ❖ Night sweats ❖ Lethargy Diagnostics: ❖ QuantiFERON gold blood test ❖ Mantoub skin test *intradermal check for 5-10 mm of induration at 48-72 hrs. International BCG vaccine also has false positives ❖ Acid fast bacilli culture (3 early morning sputum samples) ❖ Chest x-ray (active lesions in lungs) Tx: ❖ 4 long-term abx (1 year) ❖ Rifampin, Isoniazid, Pyrazinamide, and Ethambutol “RIPE” Nursing care:
- Negative pressure rooms; airborne precautions
- KN95, surgical mask
- Family screening
- will need to provide sputum samples throughout therapy (3 negative cultures; no longer infectious) ★ TB skin test should not be done on a 2 year old who was infected with RSV at 3 months and is asymptomatic ★ Do not give TB at the same time as the measles vaccine as this vaccine can make a person who is positive for TB appear to be negative! (PNMIE p.182) Atrial septal defect (ASD): Abnormal opening in wall between the two upper chambers (atria). Allows oxygenated blood that should flow to the left ventricle, into the right atrium instead. It mixes with deoxygenated blood and is pumped into the lungs 4 types -
- Secundum (75%) occurring in central part of atrial septum
- Prinum (20%) lower part; occurs with other congenital heart problems
- Sinus Venosus (4%) upper part; rare
- Coronary Sinus (1%) Risk factors: ❖ rubella infection during pregnancy ❖ Meds, tobacco, alcohol/drugs usage ❖ Obesity
****S/S of heart failure in keiki:** ❖ Tachycardia (early sign) ❖ Diaphoresis ❖ Poor feeding or FTT ❖ Cool extremities ❖ Peripheral edema ❖ Signs of respiratory distress ❖ Hepatomegaly ❖ Weight gain
- *You do not see specific left-sided or right sided S/S of heart failure b/c unlike adults, failure of one chamber causes reciprocal change in the other Nursing Care: ❖ Daily weights & peripheral edema checks ❖ O2, semi-fowler’s position ❖ Sedation/analgesics for pain or discomfort ❖ Conserve energy; bath prn, cluster care, ↓crying ❖ High calorie feedings ❖ Monitor HR, BP, electrolytes, BUN & creatinine ❖ Monitor family coping ❖ ↓heart workload ❖ ↑ tissue oxygenation ❖ Administer digoxin, ACE inhibitors, Spironolactone, Beta blockers Know Tricuspid Atresia. Anatomy and what is happening. Congenital heart defect; tricuspid valve isn’t formed between two right heart chambers. Blood flow is blocked between right atrium & right ventricle ★ Tricuspid valve is missing, enlarged right atrium, right ventricle is underdeveloped. There is ASD or sometimes VSD (hole in heart) ★ Deoxygenated blood flows directly from right upper chamber to oxygenated blood of left upper chamber through hole in wall between them (ASD) ★ Mixed blood passes to left ventricle and through VSD to right
ventricle, pulmonary artery and lungs, or mixed blood from aorta refluxes back through PDA to lungs S/S: ★ SOB ★ Cyanosis ★ Clubbing of nails d/t hypoxia ★ Tachycardia ★ Dyspnea ★ Heart murmur ★ slow growth/poor weight gain ★ HF sx (fatigue, weakness, swelling in legs/ankles/feet, SOB, ascites, sudden weight gain from fluid retention) Findings: ★ Chest XR shows cardiomegaly with enlarged right atrium & ↓ pulmonary blood flow ★ Echo is definitive by visualization of defect and shunting ★ Tx: multiple surgeries ★ Complications: infective endocarditis, brain abscess, stroke, irregular heart rhythms, kidney/liver dx, heart failure ★ ↑Pulmonary blood flow ★ Risk factors: German measles/Rubella or other viral infections during pregnancy, family hx, alcohol/smoking during pregnancy, poorly controlled DM during pregnancy, certain meds for acne, bipolar disorder & seizures Tx: Surgeries: Shunt replacement, Glen procedure, fontan procedure Understand Coping mechanisms for heart failure (i.e., Is there increased sympathetic activity, Ventricular Hypertrophy or Ventricular Dilation associated with Heart Failure?) What do you usually see?? (Ch 8 slide 58) ★ Increased sympathetic activity ↪ in response to ↓CO & BP; enhances peripheral vascular resistance, contractility, HR, and venous return ★ Ventricular dilation ↪ causes ↑ stroke work & volume during contraction, stretching muscle fibers so that the ventricle can accept the ↑ intravascular volume. Eventually the muscle becomes stretched beyond optimum limits and contractility declines.
★ Barking seal-like cough ★ Retractions, wheezing, cyanosis, obtundation (not responsive) ★ Inspiratory stridor (noisy respirations) Tx: nebulized racemic epinephrine (decrease inflammation/edema), Decadron/dexamethasone (for edema & inflammation, decreases cough, dyspnea), acetaminophen for fever & O2 consumption in febrile child, use vaporizer/humidifier at home or steamed BR, oral fluids, antipyretics. Asthma Reactive airway disease triggered by inflammatory factors, irritants, or activity induced S/S: ★ Wheezing or absence of breath sounds ★ Nasal flaring ★ Intercostal retractions ★ Recurrent productive cough (worse at night & early morning) ★ Difficulty speaking in sentences ★ Chest tightness ★ Digital clubbing ★ Cyanosis Tx: for acute exacerbations SABA albuterol to open airways (rescue inhaler), LABA salmeterol, steroids short-term ie. prednisone/prednisolone (can stunt growth; do not stop abruptly, no long-term steroids) Know what Tetralogy of Fallot is, what are the symptoms and what is a TET spell. ➢ Defect that ↓ pulmonary blood flow. ➢ Aorta sits over the VSD receiving blood from right and left ventricles. ➢ Pulmonic stenosis reduces blood flow to the lungs, thus blood with ↓O concentration exits into systemic circulation. ➢ Blood shunts right to left forcing deoxygenated blood to left side & up aorta.
4 components (“tetralogy”) ★ Pulmonary artery stenosis ★ VSD ★ Right ventricular hypertrophy ★ Overriding aorta Symptoms: ★ Cyanosis at birth (worsening in 1st year of life) ★ Systolic murmur (loud; grade IV-V/VI at left sternal border w/thril) TET Spell: Occurs d/t ↑hypoxia of blood to brain. ★ Knee-chest position 1st!! (↓ venous return and ↑ systemic vascular resistance improving oxygenation aka increase blood flow to lungs) ★ Hypercyanosis “blue spells” (hallmark sx) ★ Dyspnea; deep, sighs ★ Bradycardia ★ Syncope (preceded by crying, feeding, or BM) ★ O ★ Morphine (vasodilation) Understand the management of an infant with suspected heart disease and reported cyanosis. ❖ Cyanosis that worsens with crying is probably cardiac (↑ pulmonary resistance to blood flow = ↑ right-to-left shunt ❖ Cyanosis that improves with crying is probably pulmonary (deep breathing improves tidal volume) ❖ Congenital heart defects can cause hypoxemia, respiratory disorders and anemia ❖ Many of the defects cause an oxygenated blood to enter systemic circulation
❖ Poor feeding/growth ❖ Sweating while crying ❖ SOB, fatigue ❖ Tachycardia ❖ HF, Endocarditis Diagnostics: ❖ Echo ❖ Cardiac cath imaging Tx: ❖ Indomethacin (NSAID/prostaglandin inhibitor closing PDA) ❖ Surgical clipping if medications What is Coarctation of the Aorta, anatomy, symptoms & Complications (Listen to the narration with this slide) Coarctation of Aorta: Congenital obstructive defect; narrowing of aorta = obstructive blood flow from ventricles ★ Pressure backs up to left side of heart increasing load on left ventricle ★ Dilation of proximal aorta & ventricular hypertrophy ★ ↑ blood flow to head & upper extremities ★ ↓ blood flow to the trunk & legs Symptoms: ★ Pink arms, cyanotic legs ★ claudication (pain, cramping, numbness in legs occurring during activity & relieved by rest) ★ Bounding pulses in arms, absent/weak pulses in legs ★ Warm upper body, cool lower extremities ★ Elevated BP in arms, lower BP in legs ★ Vertigo ★ HA ★ Stroke risk ★ Nose bleeds ★ Cardinal signs: ○ Resting systolic HTN of upper body ○ absent/diminished femoral pulses
○ wide pulse pressure (difference between systolic and diastolic) Complications: ★ Turner’s Syndrome (affects females; deletion of x chromosome (X0)) ★ Aortic aneurysms, cerebral aneurysm, hemorrhage, rupture of aorta, infective endocarditis Tx: ➔ correct coarctation by digoxin (remember: this is a antiarrhythmic/cardiac glycoside = ↓HR and improves ventricular filling & ↑ contractility) ◆ monitor BP, explain restrictions, monitor for toxicity ie. poor feeding and vomiting; monitor I&O especially with diuretics/fluid restriction, daily weights ➔ Diuretics ➔ prostaglandin infusions ➔ abx prophylaxis against infective endocarditis before & after surgery In assessing a child with the diagnosis of Pulmonic Stenosis: Narrowing of pulmonic valve at entrance of pulmonary artery, interfering with right ventricular outflow to lungs ↓ blood flow to lungs Symptoms: ★ Cyanosis ★ Sx of HF (SOB, chest pain, ascites/abdominal swelling, fatigue, weakness, swelling in legs/ankles/feet, sudden weight gain from fluid retention) Anatomical obstructions: ★ Obstructed right ventricular outflow causing right ventricle hypertrophy Type of murmurs associated with this diagnosis: ★ Systolic murmur heard loudest at upper left sternal border & split S Tx: ➔ Digoxin, diuretics, anticoagulation therapy ➔ Abx to prevent endocarditis ➔ Percutaneous balloon valvuloplasty ➔ Surgical valvotomy
★ Loud murmur & fever is classic signs ★ Osler’s nodes (tender raised, subQ lesions on fingers/toes) ★ Janeway lesions (purplish macules on palms or soles ★ Roth’s spots (hemorrhagic areas with white centers on retina) ★ Splenomegaly ★ Petechiae ★ Splinter nail hemorrhages Dx: blood cultures from 3 sites: tests for normocytic/chromic anemia, proteinuria, microscopic hematuria, positive rheumatoid factor Tx: abx (penicillin & gentamicin 4-6wks; + fever reduction). Affects the tricuspid valve most often, then aortic, mitral. IF left untreated can be fatal or lead to permanent damage to valve and heart failure. Monitoring: infiltration at venipuncture site, signs of embolization, renal status, heart failure, SBE prophylaxis (dental/urogenital procedures) can introduce pathogens to blood. Kawasaki Disease Acute systemic vasculitis; inflammation of small-medium vessels throughout the body. Leading cause of acquired HD in children. Must have fever >5 days and show ⅘ clinical symptoms: ★ Bilateral conjunctivitis w/o discharge ★ Strawberry tongue & mucous membrane dryness w/possible fissures ★ Erythema of palms or soles w/peeling (usually week 2-3) & peripheral edema ★ Polymorphous rash 3 phases:
- Acute (fever unresponsive to antipyretics & abx)
- Subacute (fever subsides, continues until all clinical signs resolved, irritability, periungual desquamation/peeling around nails, arthritis of larger weight-bearing joints)
- Convalescent (all clinical signs resolved) *Assess for heart failure; ↓UO, gallop rhythm, tachycardia, respiratory distress, monitor VS, I & O, daily weights, allergic reactions Tx: IVIG (IV immune globulin) to ↓ incidence of coronary artery events if given first 10 days, blood product single infusion over 10-12 hrs, watch for allergic reaction. ASA 80-100mg/kg/day Q6H w/milk or food, decreases once afebrile for 6-8 wks for antiplatelet action (S/S ASA toxicity = hyperventilation, bleeding, tinnitus, drowsiness) Hodgkin’s lymphoma(ch.14 slide 19 &PNMIE p. 592) Malignancy/Cancer of lymphatic system, large number of abnormal B cells accumulate causing painless progressive enlarged lymph nodes, spleen, and other lymphoid tissue. Affects primarily adolescents but can be diagnosed as young as 3 years old. 90% live 5 years. S/S: ★ Enlarged/painless swelling lymph nodes (mostly in lower cervical region; occurs in neck, armpits, groin) ★ Unexplained fever 100.4 F/38 C ★ night sweats w/o fever ★ unexplained weight loss >10% body weight/past 6mos ★ severe pruritus/skin excoriation Complications: Enlarged lymph nodes can cause respiratory distress & may also compress the heart causing arrhythmias if mass is left untreated. Metastatic disease may cause anemia & decreased blood counts Diagnostics: ❖ Chest X-rays (mediastinal mass) ❖ CT & MRI (enlarged nodes in other areas) ❖ PET scan Tx: ❖ Combination therapy: COPP/MOPP chemotherapy ❖ Cyclophosphamide (Cytoxan; for children) or Mechlorethamine (adults) ❖ Oncovin ❖ Procarbazine ❖ Prednisone
