Peds UNIT III notes

1. To help relieve a hypercyanotic spell?

 Place child in Knee-chest position

2. Hypercyanotic spells are common in children?

 Tetrology “TET Spells” – Tet of Fallot

3. Describe an ASD (Atrial Septal Defect)?

 Hole in the atria that allows blood that is already oxygenated to enter the right side of the heart
and be sent back to the lungs again.
 Causes pulmonary Hypertension

4. Describe the blood flow through a patent ductus arteriosus?

 Higher pressure aorta to lower pressure pulmonary artery

5. List the signs of Dig toxicity? (select all that apply)

 (slows HR  bradycardia, Contractility), N/V, anorexia, dysrhythmia

6. Therapeutic level of Digoxin?

 0.8-2 mcg/ml

7. Which electrolyte affects dig?

 Potassium

8. List the pulse parameter for infants and older children in r/t admin. digoxin?
 Hold dig. For HR in Infants up to 2 y/o <90-110 and in Older children <70

9. Why is furosemide (Lasix) often given with digoxin?

 To pull off fluid, both affect K+, must monitor K+ levels during therapy

10. What is the action of ACE inhibitors in heart failure?

 reduces afterload, relaxes coronary artery

11. List 4 interventions for congenital heart defects? Bundle Care

 Lung & sounds
 UOP
 I/O’s
 daily wts
 irritability / feeding intolerance
 (any cyanosis or tet spells)

12. List a complication of congenital heart defect (more prone to what?)

 Resp. Infection
 CHF
 Hypoxemia
1
 13. List the 4 defect of tetralogy (tet of fallot):
 VSD,
 pulmonary stenosis,
 overriding aorta,
 right ventricle hypertrophy

14. Name a characteristic of a child with chronically low oxygen?

 Finger clubbing/small stature

15. Differentiate between Hemophilia A and Hemophilia B?

 Factor 8=A / Factor 9=B

16. How is hemophilia transmitted?

 X-Linked Recessive disorder, (unaffected male/carrier female = 50/50 chance)

17. How do you manage acute bleeding in hemophilia?

 Emergency-factor injection, followed by RICE & fluids

18. What is the most frequent form of internal bleeding for hemophilia patient?
 Hemoarthralgia (bleeding in joints)

19. How is sickle cell transmitted genetically?

 Autosomal recessive,

20. Sickle cell is not often diagnosed in infants why?

 Fetal HgB is still present

21. What are your priority interventions for sickle cell?

 Rest
 Decrease stress
 Hydrate
 prevention of infection

22. What causes the pain in sickle cell?

 Occlusion from irregularly shaped blood cells, causes tissue ischemia

23. What diagnostic test differentiates sickle cell anemia (SCA) from sickle cell trait (SCT)?
 Electrophoresis?

5 Objectives of Otitis Media Tx

Relieve Pain
Promote Drainage
Educate Family
2
Prevent Infection
Provide Emotional Support
Clinical Manifestations of Otitis Media
Acute Otitis Media
Follow an Upper Resp. Inf (URI)
Otalgia (earache)
Fever – may or may not be present
Purulent discharge (otorrhea) – may or may not be present

Infants and very young children

Crying, fussiness, restlessness, irritability, esp on lying down
Tendency to rub, hold, or pull affected ear
Rolling head from Side to side
Difficulty Comforting Child
Loss of appetite, refusal to feed

Older Children
Crying or verbalizing feelings of discomfort
Irritability
Lethargy
Loss of appetite

Chronic Otitis Media (recurring otitis media)

Hearing Loss
Difficulty communicating
Feeling of fullness, tinnitus, or vertigo may be present

24. Complication of recurring otitis media?

 Delayed speech, hearing loss

25. Prevent otitis media? (Select all that apply)

 avoid propping bottle, no bottle at bedtime, hold and sit upright during feedings
 no smoking,
 routine immunizations,
 pneumonia vaccination,
 breast feeding for at least 6 months

26. What can cause Rheumatic Fever, what is it?

 Condition in which Heart Valves (MITRAL) are damaged  R/T to Pharyngitis
 Begins with GROUP A Strep throat - Pharyngitis
 Inflammatory disease that affects many of the body’s connective tissues
 Diagnosed by guidelines rec. by AHA known as Modified Jones criteria

27. S/S of rheumatic fever?

 Rash (erythema marginatum),
 Fever
3
  MIGRATORY POLYARTHRITIS (painful, tender, red and swollen joints)
 chest pain
 facial grimacing, jerky movement (Syndenham chorea)
 SOB
 Small, painless nodules under the skin

28. Rheumatic fever (RF) treatment?

 Antibiotics (to get rid of group Strep A (penicillin or erythromyacin), Tylenol, Prednisone
 Medication rest, nutrition
 Emotional support
Secondary Prevention
o American Heart Association recommends 2ndary prophylactic tx for RF pts.
o Monthly injections of benzathine PCN G or 2 daily doses of Pen VK (penicillin) or
Erythromycin or 1 daily dose of sulfadiazine
o  Depends on presence of residual Heart disease, if have Carditis then given for 5 years

29. Nursing care / post-op teaching for tonsillectomy?

 Assess for Bleeding up to 2 wks  excessive swallowing, restlessness, vomiting bright red blood
 no red/brown liquids, no straws
 no cough/blow nose, or clearing throat, no gargling and vigorous teeth brushing
 no ibuprofen for up to 2 wks (may cause bleeding)
 no milk
 cool not hot fluids
 limit activity first week
 avoid irritating and highly seasoned foods

30. S&S of RSV Bronchiolitis:

 Retractions, nasal flaring
 Wheezing, sneezing, rhinorrhea, low-grade fever followed by Acute Resp Distress
 Lethargy
 Irritability
 poor feeding
 Tachypnea > 70 breaths per min – no feeding just IV bc of risk for aspiration

4
S/S of Respiratory Syncytial Virus Infection (RSV)
Initial
Rhinorrhea
Pharyngitis
Coughing, sneezing
Wheezing
Possible ear and eye drainage
Intermittent Fever

With Progression of Illness

Increased coughing and wheezing
Tachypnea and retractions
Cyanosis

Severe Illness
Tachypnea > 70 breaths/min
Listlessness
Apneic Spells
Poor Air exchange; poor breath sounds

31. Treatment of RSV: (droplet and standard and contact precautions)

 Symptomatic treatment (Assess Resp. status / VS, pulse Ox)
 Humidified O2 – cool mist
 Encourage Adequate fluid intake (IV therapy or PO fluids), oral as tolerated but NOT Tachypneic)
 Airway maintenance (O2 sat 90% +) (**Don’t always have to give O2, may need Suctioning)
 Medications as prescribed (racemic epinephrine may be used to improve ventilation status,
corticosteroids to dec. infammation)

32. Prevention of RSV in high risk patients: (High risk: premies, immunocompromised)
 Synagis (palivizumab) given monthly by IM injection up to 5 doses ux given in Fall, Winter, Spring
 Breast Feed 1st 6 months
 Avoid passive smoke
 Handwashing

33. How is mono diagnosed?

 Serum Blood test: Monospot

34. Manifestation of mono? (clinical manifestations last 10 days to 6 wks after exposure)
 Swollen lymph nodes (Lymphadenopathy)
 Hepatosplenomegaly  no contact sports for 2-3 months
 Fever
 Fatigue
 Laryngitis
 Increase in atypical lymphocytes
Infectious Mononucleosis
 Acute, self-limiting infectious disease caused by Eppstein-Barr Virus.  Acute stage Lasts 7-10 days
5
 35. After rehydration what diet after diarrhea should be given?
 Regular diet, no juice/soda

36. How long does the acute phase of mono last?

 7-10 days acute phase
 2-4 weeks length

Clinical Manifestations of Infectious Mononucleosis

Early Signs
Headache
Epistaxis
Malaise
Fatigue
Chills
Low-grade fever
Loss of Apetite
Puffy Eyes

Acute Disease
Cardinal Features
Fever
Sore Throat
Cervical Adenopathy

Common Features
Splenomegaly (may persist for several months) – no contact sports
Palentine Petechiae
Macular Eruption (especially on trunk)
Exudative pharyngitis or tonsillitis
Hepatic involvement to some degree, often associated with Jaundice

Acute Infectious Diarhhea / Infectious Gastroenteritis (AGE)  caused by viral, bact., parasitic pathogens
Acute Diarrhea – no form to it at all  most time caused by Rotovirus  3 mos – 24 mos.
 Sometimes we don’t want to give Lomotil, we need to sometimes let it run its course
 We want to prevent dehydration
 WASH HANDS
 Vaccination:
o Rototec  2,4,6 months
o Rotorx  2 and 4 months
Salmonella and shigella are common bacterial pathogens  infants
Giardia is common parasitic pathogens  Toddlers
ELISA done to confirm rotavirus or giardia
NORMAL UO is 0.5 – 2 ml/kg/hr

6
 S/S of dehydration
 Decreased Skin Turgor (Seen with moderate dehydration)
 Dry Mucous Membranes / decreased or absent tears (mild is slightly dry muc. Mem; Mod. is dry)
 Sunken eyes / dark circles below eyes (seen w Moderate)
 Sunken Fontanels (seen with Moderate)
 Lethargy and irritability
 Slow Capillary refill
 Rapid thready pulse, cyanosis, rapid breathing, lethargy, coma (Seen in severe)

37. Nursing Interventions acute diarrhea?

 Strict I&O
 daily wts
 Monitor IV fluids
 Administer Oral Rehydration Solution – Pedialyte (most common) as ordered
 Encourage continued feeding or early reintroduction of a regular diet ASAP
 Some may be NPO for short time then regular diet
 Keep diaper area clean and dry (skin integrity) – NO POWDERS
 WASH HANDS – teach about prevention of spreading & risk of bacteria transmitted by food

BRAT diet has little nutritional value.

38. Prevention of Diarrhea transmitted by food through bacteria– fecal oral route most common
 Quickly freeze foods (straight in fridge)
 Thaw food in fridge
 Wash everything with hot soapy water, especially after raw meat
 Cook foods to 160°

Congenital Heart Disease (4 types)

1) Left to Right Shunting  Patent Ductus Arteriosis  PDA
2) Obstructions  obstructs area
3) Flow
4) Mixed blood flow

S/S depend on severity of Defect

Can lead to HF or to hypoxemia

3 DEFECTS THAT INCREASE PULMONARY BLOOD FLOW

1) Patent Ductus Arteriosis (PDA)  Congenital heart defect where The vessel (ductus arteriosis)
connecting the aorta and pulmonary artery (PA) has failed to close at birth, which leads to a LEFT to
RIGHT shunting of blood = Increased Pulmonary Blood Flow = PULMONARY HTN.
 The ductus arteriosus is a structure that should be present in all babies in utero and should close
within 3 days of birth
 The purpose of the ductus arteriosus is to help carry blood that is entering the RIGHT side of the
heart to the rest of the body, bypassing the lungs in utero
 SYSTOLC & DIASTOLIC MACHINERY-LIKE MURMUR **hallmark sign heard L upper sternal border

7
 WIDE pulse pressure is seen with patent ductus arteriosus. Pulse Pressure is Systolic pressure –
Diastolic pressure and indicates the force the heart needs to contract.
o When blood is leaving through the extra vessel (PDA) back into PA, this will decrease
diastolic pressure (which is the pressure of the blood in the arteries when the heart is filling
or in between heart beats. This will lead to bounding pulses.

S/S of PDA – depends on size of PDA

“CALL”
Cardiac: continuous “machinery-like murmur” both systolic & diastolic, heard @ Left Upper Sternal
Border
o Endocarditis risk
o Increase HR
o WIDE Pulse Pressure = SBP-DPB difference greater than 15 mmHg in premature and 25 in
full term babies
o Heart Failure: Crackles, Dypsnea
Activity Intolerance: Fatigues Easily, sweat with activity
Lung: Pulmonary HTN, Increased Risk for Resp. Infection, feeding issues
Loss of Weight: Increase calories needed to breathe & issues with feeding = Failure To Thrive

Treatment of PDA
 Medications to assist with closure: INDOMETHECIN Prostaglandin inhibiter *for premature infants
and less than 3 day old babies. WILL NOT work on older infants, child or adults
 Invasive: Heart Cath or surgery

DECREASED PULMONARY BLOOD FLOW

Tetralogy of Fallot  congenital cyanotic heart defect w FOUR structural defects “RAPS”
Right ventricular hypertrophy – right ventricle enlarges due to increased pressure
Aorta Displacement – aorta is moved – unoxygenated & oxygenated blood mix & go into aorta
Pulmonary Stenosis – pulmonary artery and valve is so narrow
Septal defect (ventricle)

S/S of TOF - Structural Defects  “AFFLICT” – decreased pulmonary blood flow

Activity  any activity will stress heart  “tet spell”= cyanosis, SOB, Increased RR
Fingernail Changes: Clubbing  r/t chronic hypoxia, 6 mos)
Fatigues / Faints easily: r/t Decreased O2 (activity intolerance) bundle care of pt. bc they tire easily
**Lift Knee to Chest or Squats – increases systemic vascular resistance which decreases right to left
shunting which helps increase blood flow and help increase O2 levels
Inability to grow failure to thrive
Cardiac Sounds: harsh Systolic Murmur heard @ (L sternal border at 2nd ICS), feel systolic thrill
Trouble Feeding failure to thrive, low weight, small for age, decrease in mtg develop. Milestones

Treatment of TOF
 Requires surgery  cases vary
Temporary or pallative (shunt or stent to open stenosis to increase pulm. Blood flow)
Complete Repair: patch VSD (around 6-12 months) to prevent mixing of blood

8
 Alprostadil (prostaglandin E)  to keep ductus arteriosis OPEN! To allow blood to flow through
ductus arteriosis open to increase BF to PA to increase O2 rich blood to body
o For newborns w/ severe TOF w/ major pulmonary valve defect – will need temp. surgery