ATI Nursing Care of Children

PEDIATRICS REVIEW SHEET

• ATI Nursing Care of Children: Medication Admin pg 41, Pain Management pg 45

Hospitalization and Illness pg 51, Cardiovascular pg 113, Hematologic pg 125

• Fetal Heart Flow Video: https://www.youtube.com/watch?v=4Jok63Q0EN4

• I really recommend listening to the audio power point part 1 several times and looking at all the pictures and diagrams for the heart defects.

 General

• How many ml can you administer to an infant or child in a syringe?

0.5 ml for infant one month or younger

1 ml for small child 1-12 months

20 to 25 gauge

5/8 to 1-inch length

5/8 for neonate

1 inch 1-12 months

1 to 1 ¼ for 1 year to age 10

Site of choice

Age 0-2 Vastus Lateralis

Age 2-12 Vastus Lateralis, Ventrogluteal, Deltoid

• What is the order of an assessment in a young child?
• Go from least threating to most threating
• Assess when asleep, stay child’s level, have child in parent’s lap
• Utilize toys, games, take extra time if needed, but if child remains uncooperative, be firm and work quickly
• Focus on priority complaint first
• Be honest if something will hurt

Vital Signs

Respirations: Do when sleeping or quiet, under 7 look at abdomen to count RR, count for full minute, infants count for several minutes, to listen to lung sounds make it a game

Pulse: Older than 5 radial is okay, under 5 apical for full min

Blood Pressure: 3 and older for well child exam, done prior to upsetting events, done on all ages if hospitalized, make sure to use proper cuff, explain what is going on, that it will be snug and what will feel like, do not choose cuff based on name, choose based on upper arm length

Temperature: Tympanic or temporal, newborns/nicu temps are unstable

• How do you do a height and weight on an infant/child?

Weight

Fluid loss and inadequate calories are reflected in a child’s weight, especially that of infants and toddlers.

Perform in warm room

Same scale should be used, and the child should be weighed at the same time every day.

Babies should be in diaper; Older children gown/underpants

Zero scale for arm boards, diapers, or other equipment

• Diapers can be weighed for I&O, weight dry diaper then wet

Length

Measurements are taken when children are supine, recumbent length is usually measured until 2 years of age

Height

Measurement is of a child standing upright, feet flat

• What are the criteria for administering CPR to an infant?

• Heart rate less than 60

• What is Clark’s rule? What is Young’s rule? How do you calculate safe doses?

Clark’s Rule: Uses weight (always pounds!), divide by 150, multiply by adult dose and the answer is the child dose

Young’s Rule: Uses age, child’s age plus 12, then divide by the +12 number, multiplied by the adult dosage

Safe Dosage: States safe dose based on mg/kg per day 

Registered Nurse RN: Safe Dose Video https://www.youtube.com/watch?v=QRdIVGaQf7Q

 Heart

• What is a cyanotic heart defect?

• A Right to Left Heart Defect like Tetralogy of Fallot and Transposition of Great Vessels

• What defect produces cyanosis?

• Tetralogy of Fallot due to the TET spells and severe cyanosis at birth

• What heart defect is incompatible with life unless there is an accompanying defect?

• Transposition of Great Vessels

In this disorder, the pulmonary artery arises out of the left ventricle; aorta arises from right ventricle

Usually fatal without treatment or without PDA, ASD or VSD to mix blood

Venous blood exits out of right side of heart via aorta back into circulation without ever being oxygenated

Oxygenated blood returning from the pulmonary system keeps circulating back to the lungs

• What are the treatments for all the heart defects?

• Left to Right Shunt Defects:

PDA Treatment

Indomethacin: Prostaglandin inhibitor effective in closing PDA especially in premature infants, if meds do no close, surgery may be required

Occasionally requires surgery: Ligation of PDA, or clip placed; small incision between ribs or through catheter in groin

Transcatheter device placed in blood vessel then small metal coil passed into site of PDA to block it off so blood can’t pass

• ASD Treatment
• 50% will close on its on

• If surgery is necessary, small areas are sewn together, larger areas used a Dacron patch, surgery done about 2-4yrs old

• Can close by going through groin and inserting catheter into blood vessel, then into heart; closure device placed across the ASD

• VSD Treatment

50% close spontaneously during first 2 years of life

Others may require surgery with patch

• Right to Left Shunt Defects/Decreased Pulmonary Blood Flow:

• Tetralogy of Fallot Treatment

Palliative procedure performed in infants with profound cyanosis, temporary procedure to shunt blood back to lungs for oxygenation

Later surgery to correct all defects

May need pulmonary valve replacement

• Transposition of Great Vessels Treatment

Initially, palliative procedures to provide mixing by creating ASD

O2 therapy may be harmful: May enhance closure of PDA which may be only source of mixing of blood

Decrease stress factors for infant to decrease cardiac workload

Prostaglandin E to maintain PDA: maintain the mixing of blood (prostaglandins keep PDA patent

Enlarge an already existing defect (cardiac cath with atrial balloon)

Complete correction occurs with switching vessels to proper place; usually done in first week called Atrial Switch, but has good outcomes

• Obstruction Defect

• Coaction of Aorta Treatment
• Surgeries

End to End Anastomosis for small sections (cut out narrow part)

Graft for larger sections

May do balloon angioplasty to stretch and widen, but higher rate of failure

• Best to do surgery soon after birth so child and graft can grow together

• Acquired Defect

• Rheumatic Fever Treatment

Treat underlying strep with penicillin or erythromycin, must take entire course

Prevent cardiac damage: corticosteroids for carditis (observe for early signs)

Comfort measures for S/S

Prevention of recurrent strep with penicillin prophylaxis: daily doses or monthly IM injections after acute phase; treatment for 5 years or until 21 whichever is longer

Bedrest to reduce heart workload for patients with active carditis

• What are the signs and symptoms in coarctation of the aorta?

Coarctation means tightening

Narrowing of lumen of aorta resulting in increased pressure proximal to defect and decreased pressure distal to defect

Think squeezing a garden hose, the water pressure will be higher behind kink

Impedes blood flow to lower portion of body

Signs and Symptoms

Increased BP in arms vs. legs (>20mmHg different)

Pulses in upper extremities are bounding

Pulses in lower extremities are weak or absent

Older children complain of leg cramping, fatigue, nosebleeds

• What are the signs and symptoms in Tetralogy of Fallot?

Severe cyanosis at birth

TET spells (blue spells): acute episodes of severe cyanosis and hypoxia; sudden restlessness, gasping respirations, increasing cyanosis

Can lead to loss of consciousness, convulsions; especially after exertion like feeding or crying—child’s skin, lips, tongue bluish tint

Murmur

Clubbing of nails

Dyspnea, squatting (knee-chest position decreases venous return by occluding femoral veins thus lessening workload of right side of heart)

Failure to thrive/growth problems

Syncope

Increased RBCs in effort to compensate for lack of oxygen (Increased HCT)

• What is Rheumatic fever? What is the treatment? What is the priority action during the acute phase?

Signs and Symptoms

Slow onset, child listless, anorexic, pale

Low-grade afternoon fever

Lose weight

Complain of vague muscle pain, migratory joint pain, inflammation

Skin rash on trunk, upper extremities

Leads to cough, chest pain, dyspnea

May develop chorea (rapid, jerky movements)

Strep releases toxin that cause antibody formation; antibodies react with tissue antigens and cause damage in different tissues leading to autoimmune reaction

Autoimmune complexes attach heart with bulk of scarring/damage to mitral and aortic valves; can lead to heart failure, pericarditis, endocarditis, myocarditis

Treatment

Treat underlying strep with penicillin or erythromycin, must take entire course

Prevent cardiac damage: corticosteroids for carditis (observe for early signs)

Comfort measures for S/S

Prevention of recurrent strep with penicillin prophylaxis: daily doses or monthly IM injections after acute phase; treatment for 5 years or until 21 whichever is longer

Bedrest to reduce heart workload for patients with active carditis

 Hematologic

• What are the lab tests done for hemophilia and what do the results show? What causes the most concern?

Labs:

Normal prothrombin time, INR, bleeding time, platelet count

Abnormal Prolonged partial thromboplastin time (PTT)

Abnormal clotting factors 8/9 low

• Intercranial hemorrhage and ICP causes the most concern because it could become life threatening

• What are three things that leukemia causes?

Acute Lymphoblastic Leukemia (ALL): Uncontrollable proliferation of blast cells (immature WBCs) that accumulate in bone marrow

Crowds and depressed other healthy cells

More blast cells means decreased WBCs, decreased RBCs, decreased platelets

Signs and Symptoms

Pallor, fever, infection (decreased WBCs—leukopenia)

Tiredness (decreased RBCs—anemia)

Bleeding, petechiae, bruising (decreased platelets—thrombocytopenia)

Bone pain, joint pain

Enlarged lymph nodes, glands, hepatosplenomegaly (liver/spleen)

• What are the types of crisis that occur in sickle cell anemia?

Vaso-occlusive: Small vessels blocked in hands/feet which leads to pain, edema, impaired ROM from tissue hypoxia

Sequestration: Blood pools in liver and spleen, can progress to cardiovascular collapse, death

Aplastic: Premature destruction of RBCs because of sickle shape and results in profound anemia, causes bone marrow to stop producing RBCs

• How do we diagnose sickle cell? What are the priority actions?

Diagnosis:

Sickledex used for screening, adds deoxidating agent to blood and if 25% of Hgb sickles, test is positive.

Hgb Electrophoresis uses electrical charge to separate normal and abnormal to determine trait or disease and uses umbilical blood to screen newborns in nursery

Treatment

IV fluids to maintain hydration

Oxygen to correct hypoxia

Pain management: analgesics (mild: ibuprofen/acetaminophen; severe: morphine, hydromorphone—Dilaudid); meperidine (Demerol) contraindicated due to increased risk for seizures

Supplement with folic acid: needed to produce RBCs

PRBCs, BR

Always use heat—cold aggravates condition

Prophylactic antibiotics—prevents infections

Hydroxyurea: severe cases; reduces frequency of crises; stimulates production of HgbF

Bone marrow transplant

Splenectomy: for enlargement; more prone to infection afterward

• ITP…what is it? What is the treatment? What is our greatest concern?

Marked decrease in platelets resulting in bleeding beneath skin

Acute Form: Follows viral infection, self-limiting, last 6 months or less; kids affected

Chronic form: Periods of remission; mostly adults affected

Signs and Symptoms

Child appears healthy but has bleeding problems

Platelet count decreased: below 20,000

Bruising and pinpoint petechiae first S/S over bony prominences

Can have bleeding anywhere: gums, nosebleeds, intracranial, hematuria

Acute Treatment

Let illness run course; most recover in 3 months, platelet count will return to normal in 6-12 months

Corticosteroids: suppress immune attack on platelets

IV gamma globulins: concentrated antibodies; help to block destruction of platelets

Platelets and blood as needed if there is a life-threatening problem

Chronic Treatment

Splenectomy: Eliminates site of antibody formation, removes risk of hemorrhage

Blood and vitamin K to correct anemia and coagulation defects

Teaching: Protect from injury; no aspirin, ibuprofen (thin blood); call immediately with head injury