Pediatric Nursing Edison O. Dangkeo, RN
Pediatric Nursing Edison O. Dangkeo, RN
Pediatric Nursing Edison O. Dangkeo, RN
4. Growth and Development occurs in a regular direction reflecting a definite and predictable patterns or trends
DIRECTIONAL TRENDS- occurs in a regular direction reflecting the development of neuromuscular functions:
these apply to physical, mental, social and emotional developments
Cephalo – caudal: “ head to tail”. It occurs along body’s long axis in which control over head, mouth and
eye movements and preceeds control over upper body torso and legs.
Proximo–distal: from center of the body to extremities
e.g. baby uses whole arm in crawling then hand pincers
Symmetrical: each side of the body develop on the same direction at same time and rate
Mass-Specific (Differentiation): the child learns from simple operations before complex functions or move
from a broad general pattern of behavior to a more refined pattern. E.g. Crying infant suggests wet diaper,
hunger, thirst or pain until can use words for milk etc.
2
aoih0718
Pedia
SEQUENTIAL TRENDS- involves a predictable sequence of growth and development to which the child normally
passes
a. locomotion
b. language and social skills
SECULAR TRENDS-refers to the worldwide trend of maturing earlier and growing larger as compared to
succeeding generations
3
aoih0718
Pedia
• Present at 3 mos
K. Parachute reaction- while on ventral suspension, sudden change in equilibrium causes extension of arms
and legs
• Abnormal: collapse of the baby in limp, concave position
• Present at 6-9 mos.
L. Babinski- sole of foot stimulated by blunt object in inverted J causes fanning/ dorsiflexion of all toes
• Abnormal: fanning of great toe only
• Present due to immature CNS; myelinization is not yet complete
• Disappears at 2 mos to 2 yrs
THEORIES OF DEVELOPMENT
• DEVELOPMENTAL TASK- a skill or growth responsibility arising at a particular time in the individual’s life.
The successful achievement of which will provide a foundation for the accomplishments of the future tasks.
PSYCHOSEXUAL THEORY
• or Psychoanalytic Theory
• Sigmund Freud (1856-1939) – an Austrian neurologists, founder of psychoanalysis
• Libido (sexual energy) goes to one part of the body to another where it is responsible for survival
5 PHASES
1. ORAL- (0-18 mos) Infant
mouth- site of gratification
Activity: biting, sucking, crying (for enjoyment and release of tension)
Never discourage thumb sucking
Offer pacifier when NPO
ID- source of all drives; present at birth; striving for gratification of needs
EGO- for reality testing and problem solving, develops at 4-5 mos. When infant begins to see self separate
from mother (development of sense of self)
PSYCHOSOCIAL THEORY
• Erik Erikson- trained in psychoanalysis theory
• Focuses on psychosocial tasks that are accomplished throughout the life cycle
• Stresses the importance of culture and society to the development of one’s personality
• Unsuccessful resolution of psychosocial crisis leaves the individual emotionally handicapped
4
aoih0718
Pedia
8 STAGES
1. Trust vs Mistrust (0-18 mos) *Feeding
Foundation of all psychosocial tasks
Psychosocial Theme: “To give is to receive”
Developed by:
Satisfying needs at all times: feed upon demand (because stomach capacity is low and baby easily
gets hungry
Parental caring must be consistent and adequate
Giving an experience that will add to security (e.g. touch, hugs and kisses, eye-to-eye contact, soft
music)
2. Autonomy vs Shame and Doubt (18 mos- 3 yrs) Toddler *Toilet Training
If everything is planned or done for the child, autonomy is not developed
Developed by:
Giving opportunity for decision-making, offering choices, rather than judge
Setting limits is the parents’ moral obligation
COGNITIVE THEORY
• Jean Piaget- Swiss Psychologist
• Defines cognitive acts as ways in which the mind organizes & adapts to its environment
• SCHEMA- individual’s framework of thought
A. Sensorimotor (0-2 yrs): “Practical Intelligence”, words and symbols not yet available
5
aoih0718
Pedia
Circular Reaction
Tertiary Circular Reaction 12-18 mos Use trial and error in discovering places and events,
space and time perception
Invention of new means thru 18-24 mos Invent new means by active experimentation,
mental combination Transitional phase to Preoperational thought period
12 Adoles-cent Post Conventional (Level III) Social contract, utilitarian law- making perspectives.
5 Follows standards of society for the GOOD OF ALL
people
12 6 Universal ethical principle orientation. Follows
Adolescent INTERNALIZED STANDARDS of conduct
DEVELOPMENTAL MILESTONES
INFANCY
• PLAY: Solitary, non-interactive (begins at 4 mos)
• BEST TOYS: mobiles, teethers, music box, rattles
• FEAR: Stranger anxiety
– Begins at 6-7 mos
– Peaks at 8 mos
– Fades at 9 mos
NEONATE
• Largely reflexes
• Complete head lag
• Hands fisted
• Cries without tears
• Visual fixation for human face
1 MONTH
• Dance reflex disappears
• Looks at mobiles
– Prefers checker boards with angles and not pastel colors with contours
– Hang at least 8 in. (20 cm) from head
2 MONTHS
• Holds head up when in prone
• (+) Head lag when pulled to sitting position
• (+) Social smile
• Cries with tears
• Closure of posterior fontanel (2-3 mos)
3 MONTHS
• Holds head and chest up when in prone
• Follows object past midline
• Palmar grasp and tonic neck reflexes are fading
• (+) Hand regard
• Coos, Bubbles
4 MONTHS
• Turns from stomach to back, needs space to turn
• Complete head control when pulled to sitting position
• Solitary play begins
• Laughs aloud
• Recognizes mother
5 MONTHS
• Assumes crawling stance
• Places objects in mouth (give teething rings)
• Handles rattle well
• Moro reflex disappears (4-5 mo)
• Reaches out to be held
• Cries when toy is removed
6 MONTHS
• Rolls from back to stomach
• Sits with support
7
aoih0718
Pedia
CONCERNS: INFANTS
• COLIC
– Paroxysmal abdominal pain, common among < 3 mos.
– S/Sx: Loud crying, flushed face, fists clenched, tensed abdomen
– Causes:
• Overfeeding
• Swallowing of too much air
• Milk formula very high in CHO
• Tensed mother during breast feeding
– Management:
• Burp baby in the middle and after breast feeding or every 1 oz. of milk formula
8
aoih0718
Pedia
• Keep baby in upright position on mother’s chest or shoulder or in R side lying position on
mother’s arm/lap
• CONSTIPATION/DIARRHEA
– Causes:
• Inaccurate mixing of formula
• Adding too much sugar
• Not diluting milk properly
• Using condensed milk
• Introduction of solid foods with too much fruits/sweets
• WEANING- during 6 months
– Criteria
• Child is able to approximate lips to the cup
• Child begins to experience ↓ sucking intensity
– Choose a good day/mood for best cooperation
– Don’t rush it
– Don’t set time table
– Provide reassurance that giving up breast/bottle doesn’t mean end of physical contact with mother
• NIGHT BOTTLE SYNDROME
– Bedtime bottle is hardest to give up
– Danger of propped bottle
• Tooth decay
• Aspiration, may lead to pneumonia
TODDLER
• PLAY: Parallel (2 toddlers playing separately); provide 2 similar toys
• BEST TOYS: waddling duck, pull-push trucks, tricycle, building blocks, pourding peg, erector set
• FEAR: Separation anxiety
• Begins at 9 mos
• Peaks at 18 mos
• PHASES: Separation anxiety
1. Protest: crying, screaming, searching for a parent, rejects stranger
2. Despair: withdrawn, depressed, uninterested
3. Denial/Detachment: uncommon, occurs only after lengthy separation
• Copes by forming shallow relationship with others, being self-centered & attaching primary importance
to material objects
• Detaches from parents to escape the emotional pain of desiring parent’s presence
• A form of resignation, not of contentment
TEMPER TANTRUMS
– Reasons:
• Inadequate vocabulary to express feelings in a socially-acceptable manner
• Response to unrealistic requests of parents
• Response to difficulty in making choices/decisions
– Ignore the behavior
• Rigid, stereotype
• RITUALISTIC/DAWDLING- wasting a lot of time accomplishing a task
– Reasons:
• Asked to do something that is too difficult for them
• Short attention span to remain interested in the task
– Give ample amount of time for mastery
• TOOTH BRUSHING
– 2-2½ yrs: start of tooth brushing
– 3 yrs: tooth brushing with little assistance
– 6 yrs: tooth brushing alone
10
aoih0718
Pedia
– Right time to bring the child to the dentist: when temporary teeth are complete (at 30 mos)
• TOILET TRAINING
– 3 Clues:
• Can stand, squat and walk alone
• Can communicate toilet needs
• Can maintain dryness for an interval of 2 hrs
PRESCHOOL
• Idea about death: a form of sleep, reversible
• Beginning development of conscience thru punishment and reward
• PLAY: Associative/ Cooperative
• BEST TOYS: play house, modeling clay, finger paints, dolls, cars, doctor’s set
• FEARS: Body Mutilation/ Castration fear, dark places, witches, ghosts, thunder and lightning
BEHAVIOR PROBLEMS
• Telling tall tales: brought by over imagination
• Imaginary playmate: way to release tension and anxiety
• Magical Thinking: transductive reasoning (fat means pregnant)
• Sibling rivalry: esp. among 4 yrs, jealousy to a newly delivered baby
• Preschooler regresses: bed wetting, thumb sucking, baby talk
• Masturbation: sign of boredom; divert attention by offering a toy
SCHOOL AGE
11
aoih0718
Pedia
• PLAY: Competitive
• FEAR: School Phobia
– Causes:
• Separation anxiety
• Overprotective parent and overdependent child
• Strict teacher
• New activities in school
– Resolve underlying cause
– Spend time with the child, orient child to the new environment
– Make child secure
• OTHER FEARS: Displacement from school, loss of privacy, death
• Idea about death: (7-9 yrs) permanent loss of corporal life
• SIGNIFICANT OTHERS: teacher and peers of same sex
• SIGNIFICANT DEVELOPMENT
– prone to greenstick fractures
– have a mature vision
6 YEARS
• Boys and girls are of same height
• Year of constant motion/ Clumsy movements
• Can ride a bicycle
• Temporary teeth begins to fall, permanent teeth begins to appear (1st molars)
• Defines words by their use
• Recognizes all shapes
• Begins to interact with God
• Teacher: authority figure
• Nail biting common
BEHAVIOR PROBLEMS
• Can’t bear to lose they will cheat, lie and steal
• Reasons for cheating
– Imitating adults
– Depends on practicality of the situation
• Reasons for lying
– Confusion in child’s cognitive abilities and egocentrism
– Inability to separate make believe/fantasy from reality
– Failure to come up with expectations
• Reasons for stealing
– Confusion over perceived ownership
– Impulse of peer pressure
– “Getting back” on embarrassing parents
GIRLS BOYS
Increase in size of breasts (Thelarche-1st sign) and Appearance of axillary and pubic hair (Adrenarche)
genitalia (until 18 yrs)
Widening of hips Deepening of voice
Appearance of axillary and pubic hair Development of muscles
Menarche-last sign Increase in size of testes and penis- 1st sign (until 17
yrs)
Production of viable sperm- last sign (nocturnal
emission by 17 yrs)
ADOLESCENT
• Age of transition from childhood to adulthood
• FEARS: obesity, acne, death, homosexuality, replacement from friends
• SIGNIFICANT OTHERS: peers of opposite sex
• SIGNIFICANT DEVELOPMENT:
• Conflict between own needs of sexual satisfaction and societal expectations
• Core concern: change of image and acceptance of opposite sex
• Distinct odor: due to stimulation of Apocrine glands
• PERSONALITY TRAITS
• Idealistic, rebellious, reformers, conscious with body image
CONCERNS
• Motor vehicular accidents
• Masturbation: causes conflict with morality
• Peer Pressure: smoking, alcoholism, drug addiction, premarital sex
• Body image: eating disorders affecting nutritional state
• Anorexia nervosa
• Bulimia (Binge-eating)
FETO-P
FETO-PLACENTAL CIRCULATION
Placenta→ Umbilical vein (O2 blood)→ liver→ Ductus venosus→ IVC→ RA
( pressure, 70% blood)→ Foramen Ovale→ LA→ mitral valve→ LV→ Aorta→LE
Remaining 30% blood→ tricuspid valve → RV → PA → lungs (non-functioning, for nourishment)→ lung
vasoconstriction → Ductus arteriosus → Aorta → UE
LE & UE (unO2 blood) → placenta (for oxygenation via simple diffusion)
SYSTEMIC CIRCULATION
15
aoih0718
Pedia
TEMPERATURE REGULATION
Goal: to maintain T not <36.5 °C or 97.7 °F
Factors leading to Hypothermia
– Prematurity: poikilothermic (cold blooded)- easily adapt to T of envt due to immature
thermoregulating system (Hypothalamus)
– Thin skin and ↓ SQ fats
– Inability to shiver
– Born wet
16
aoih0718
Pedia
2. Metabolic acidosis- due to catabolism of brown fat or brown adipose tissue (best insulator of NB, found at
neck, kidneys and adrenals) → formation of lactic acid and ketone bodies
3. Kernicterus- due to build-up of bilirubin in the brain
4. Additional fatigue to already stressed heart
Baby sucking on breasts→ Posterior Pituitary Gland→ Oxytocin→ Contraction of lactiferous tubules→ Milk Ejection
(Let down) Reflex
Engorgement
Feeling of tension/fullness
Management:
warm compress if breast feeding
cold compress or supportive bra if bottle feeding
Sore Nipple
Cracked, wet painful nipple
Management:
Exposure of affected breast to air or to 20-watt bulb 12-18 in. away from breast
Avoid using plastic liner bra
Mastitis
Breast inflammation due to Staphylococcus aureus
18
aoih0718
Pedia
Causes:
Improper breast emptying
Unhealthy sexual practices
Improper hygiene
Management:
Manually express infected breast but don’t feed this milk to the baby
Take antibiotics as ordered and continue breast feeding
Different Stools
– Meconium (Physiologic Stool)
• Blackish, greenish, sticky, tar-like, odorless (due to sterile intestines)
• Contents: amniotic fluid, shedding of intestinal mucosa and secretions/mucus, vernix,
hormones
• N: passed within 24-36 hrs, otherwise with GI obstruction:
Hirschsprung’s disease
Imperforate anus
Meconium ileus (Cystic fibrosis)
– Transitional Stool
• On 2nd to 10th day in response to feeding pattern
• Greenish, loose, slimy, like diarrhea to untrained eye (esp. primi mothers)
– Breastfed Stool
• Golden yellow, soft, mushy with sour milk smell ( lactic acid)
• Frequently passed: 3-4X/day
– Bottle-fed Stool
• Pale yellow, formed, hard with typical offensive odor
• Seldom passed: 2-3X/day
– With supplementary foods added
• Brown, odorous
APGAR SCORE
Special Considerations
– 1st 1 min: general condition of the baby
– 1st 5 min: capability to adjust to extrauterine life (MOST IMPORTANT)
19
aoih0718
Pedia
Interpretation of Score
– 0-3: severely depressed, needs CPR, NICU admission
– 4-7: moderately depressed, needs additional suctioning and O2
– 8-10: good health
PEDIATRIC CPR/ACLS
Mostly rooted from respiratory failure→ hypoxia if >5 min→ irreversible brain damage→ brain death
A-irway (Open and Clear Airway)
Shake→ NR→ call for help
Head-tilt-chin-lift (Sniffing position) or Jaw thrust if with head/neck (cervical) injury is suspected
C-irculation
– Obtain IV access:
• NB: umbilical vein
• Peripheral (3 attempts within 90 sec)
• <6 yrs: intraosseous (anterior tibia)
• Central line (femoral, subclavian, jugular veins)
– Give meds
• Atropine: 0.02 mg/kg IV, IO, ET
• Epinephrine (q 3-5 mins)
– 1st dose: 0.01 mg/kg IV, IO
– 0.1 mg/kg ET
– 2nd dose: 0.1 mg/kg IV, IO, ET
– Meds that can be given per ET
• L-idocaine (1 mg/kg) for PVCs
• E-pinephrine
• A-tropine for bradycardia
• N-aloxone (0.01mg/kg)
– Should be flushed with 3-5 cc plain NSS then followed by several positive pressure breaths
– Give 20cc/kg crystalloid solution (plain NSS or plain LR) as rapid IV bolus for 2-3 times until
hypotension is corrected
– If failed or in case of trauma with massive blood loss: give 10cc/kg colloid solution (Prbc), or
20cc/kg whole blood IV bolus, may give O negative blood immediately, don’t wait for crossmatching
result.
CRITERIA
Chest movement (upper
chest)
Temp (warmand dry)
0
Synchronized
1
Lag on inspiration See-saw
2
Interpretation of Score
Breathing (stimulate t
21
aoih0718
Pedia
PRETERM BABIES
20-37 wks AOG
Abundant lanugo
Hypotonia (prone to respiratory problems)
Frog leg or lax position
Irregular RR with periods of apnea
Hypothermic
Poor suck and swallow reflexes
Thin extremities and skin
Male: Testes undescended
Female: Labia narrow
Classic Signs:
Scarf sign: elbow passes midline of the body
Heel to ear sign
Square window wrist: 90° angle
POSTTERM BABIES
>42 wks AOG
Classic Sign: Old man’s face
Wide and alert eyes
Long brittle fingernails
Skin desquamation
Profuse scalp hair
Long, thin body
Meconium staining (on nails and umbilical cord)
Hypoglycemic
Crede’s Prophylaxis
Purpose: to prevent Opthalmia Neonatorum (Gonnorheal Conjunctivitis) from mother with untreated
gonorrhea and Chlamydia trachomatis if delivered via NSD
May be delayed until an hour or so after birth to facilitate eye contact & parent-infant bonding
Uses:
Erythromycin (0.5%) or Tetracycline (1%) 23phthalmic ointment (from inner to outer
canthus) or drops
Silver Nitrate 1% 2 gtts at lower conjunctival sac then washed with plain NSS after 1 min.
to prevent staining (obsolete use because cannot protect against Chlamydial infection &
can cause chemical conjunctivitis)
Administration of Vitamin K (Phytomenadione: Aquamephyton, Konakion, Cycomin)
To prevent hemorrhage r/t physiologic hypoprothrombinemia (because Vit K is not synthesized until
intestinal bacteria are present)
Preterm: 0.5 mg IM; Term: 1.5 mg IM
Via Vastus lateralis or lateral anterior thigh (Rectus femoris)
Weight taking
N: 3- 3.4 kg or 6.5- 7.5 lb
Arbitrary Lower Limit: 2.5 kg
Low Birth Weight: <2.5 kg or 5.5 lb
Small for Gestational Age: ≤ 10th percentile rank on the intrauterine growth curve
Large for gestational Age: ≥ 90th percentile rank, macrosomia > 4 kg
Appropriate for Gestational Age: within the 2 standard deviation of the mean
Physiologic Weight Loss: 5-15% of birth weight during the 1st wk of life r/t voiding and limited intake
VITAL SIGNS
TEMPERATURE
• N: 36.5-37.5 °C
• Take rectal temp. once to r/o imperforate anus
• Insert about 1 inch of the thermometer, if pushed deeply→ peritonitis
23
aoih0718
Pedia
IMPERFORATE ANUS
• Congenital disorder, incomplete development or absence of anus in its position in the perineum
• More common in M than F
• 4 types
1. Atresia (anal or rectal)
2. Agenesis (anorectal)*no anal opening, most dangerous type
3. Stenos
4. Membranous* has anal opening
• POSTURING
• Hypotonia
• Opisthotonus
• HR: persistent or ↓, (+) murmurs
• RR: , retractions with alar flaring, gasping, dyspnea with diaphoresis when supine, grunting with
exertion such as crying or feeding
• FEEDING BEHAVIOR
• Poor suck due to lack of energy and dyspnea
• Difficult, uncoordinated suck, swallow and breathing
• Slow, with pauses to rest
• Poor weight gain
• 2 MAJOR TYPES
• ACYANOTIC HD
• L to R shunt
• 50% enters the aorta, 50% reenters RV
• CYANOTIC HD
• R to L shunt
• with venous admixture entering the systemic circulation
CARDIAC CATHETERIZATION
• Fluoroscopy-guided insertion of radiopaque catheter inserted thru peripheral blood vessel (femoral or
antecubital vein) via percutaneous puncture, combined with angiography (injection of contrast material/dye)
thru the catheter into the circulation
• Provides information about:
• Oxygen saturation (saO2) of chambers and great vessels
• Pressure changes
• Cardiac Output (CO) and Stroke Volume (SV)
• Anatomic abnormalities
• Nursing Interventions: Pre-op
– Measure accurate height/length and weight: essential to correct cath selection
– Ask for hx of allergy to seafoods/iodine/dye
– WOF S/Sx of infection at site to be used: severe diaper rash defers femoral approach
– Check for presence and quality of both pedal pulses and mark them
– Get baseline VS esp. saO2
– Give analgesic/sedative as ordered (Demerol/Midazolam/ Ketamine/Propofol)
– NPO 6 hrs pre-op, with IVF to prevent hypoglycemia and dehydration as ordered
• Nursing Interventions: Intra-op
– WOF arrythmia during catheter insertion
– WOF feeling of warmth, N/V, restlessness and headache, urticaria, flushing during injection of dye
– Monitor VS: bradycardia, hypoTN may indicate hemorrhage or cardiac perforation
• Nursing Interventions: Post-op
– WOF hemorrhage
• Maintain occlusive, water proof dressing at site
• Check dressing for bleeding
• Check site for hematoma
• Ensure adequate fluid intake to prevent dehydration (due to blood loss, NPO status and
diuretic action of the dye) and hypoglycemia
– WOF thrombus formation
• Check equality and presence of distal pulses
• Check for T and color of affected extremity
• If (+) venospasm: warm compress on contralateral extremity
• Keep affected extremity straight to facilitate healing
• Venous: 4-6 hrs
• Arterial: 6-8 hrs
• Give pain meds as ordered
25
aoih0718
Pedia
NORM
• Pulmonary Blood Flow
– Ventricular Septal Defect (VSD)
– Atrial Septal Defect (ASD)
– Endocardial Cushion Defect (AV canal)
– Patent Ductus Arteriosus (PDA)
Obstructive Defects
– Pulmonary Stenosis (PS)
– Aortic Stenosis (AS)
– Duplication of aortic arch
– Coarctation of the Aorta (COA)
PULMONARY STENOSIS
• Narrowing of pulmonic valve
• Extreme form: Pulmonary Atresia: no blood flow to the lungs, with hypoplastic RV
• PDA compensates by shunting blood from aorta to PA
• With ASD due to RA and RV pressure
• Signs and Symptoms
• Cyanosis (due to ↓ pulm. blood flow)
• Typical murmur
• Split S3 sound (in all CHF)
• ECG: RV hypertrophy
• Management
• Balloon angioplasty (to dilate narrow valve)
• Transventricular (closed) valvotomy or Brock Procedure (infant)
• Pulmonary valvotomy with CP bypass (child)
AORTIC STENOSIS
• Narrowing of aortic valve
• Only 50% of blood enters aorta
• Signs and Symptoms
• Feeding/exercise intolerance
• Exercise intolerance, Active child may experience angina-like Sx: chest pain, dizziness, headache
• Faint pulses, HR, ↓ BP,
• Typical murmur, rough systolic sound and thrill
• ECG/CXR: LV hypertrophy due to LV resistance and LA pressure → pulmonary HTN and edema
• Management
• Balloon Angioplasty: done in cath lab
27
aoih0718
Pedia
Mixed Defects
• Transposition of Great Arteries (TGA)
• Total Anomalous Pulmonary Venous Return (TAPVR)
• Truncus Arteriosus (TA)
• Hyploplastic Left Heart Syndrome (HLHS)
28
aoih0718
Pedia
TRUNCUS ARTERIOSUS
• PA and aorta arise from 1 single vessel of a common trunk with VSD
• Signs and Symptoms
• CHF
• Cyanosis and hypoxemia, murmur
• Poor growth
• Activity intolerance
• Complications: brain abscess, bacterial endocarditis
• Management
• Modified Rastelli procedure: VSD patch closure + excision of PA from aorta and attaching them to
RV via homograft
• Cx: HF, bleeding, PA HTN, arrythmia, residual VSD
TRICUSPID ATRESIA
• Failure of tricuspid valve to open
• With ASD and VSD, sometimes with PDA
• Signs and Symptoms
• Cyanosis, HR, RR, dyspnea at birth
• Chronic hypoxemia with clubbing (older child)
• Complications:
• Bacterial endocarditis
• Brain abscess
• CVA
• Management
• Prostaglandin E1 IV at 0.1mg/kg/min to keep PDA open
• Palliative: Balloon Atrial Septostomy (if with ↓ pulm. blood flow)
• PA banding (if with pulm. blood flow)
• Bidirectional Glenn shunt
• Modified Fontan Procedure
TETRALOGY OF FALLOT
• 4 Anomalies Present
29
aoih0718
Pedia
– P-ulmonic stenosis
– V-SD (large)
– O-verriding of aorta
– R-V hypertrophy
• Signs and Symptoms
– acute cyanosis at birth that progresses over 1 yr as PS worsens
– murmur
– Polycythemia→thromboembolism→ CVA
– Severe dyspnea relieved by squatting (older child) or knee-chest position (infant): ↓ venous return,
lung expansion
– Growth retardation
– Clubbing of fingers and nails
– Tet/Blue spells: acute episodes of cyanosis and hypoxia
– Anoxic spells: when O2 demand> supply, usually during crying and after feeding
– Syncope’
– MR
– CXR: boot-shaped heart
• Complications:
– Seizures, Brain abscess
– CVA, or sudden death after anoxic spell
• Management
– O2 and Morphine for hypoxic episodes
– Propranolol (Inderal) to ↓ heart spasm
– Palliative: Blalock Taussig Shunt (BTS)
• pulm. blood flow and saO2 to the PA from L or R subclavian artery
– Complete: Open heart (median sternotomy) with CP bypass, includes
• Resection of infundibular stenosis (Brock Procedure)
• VSD patch closure
• Pericardial patch to enlarge RV outflow tract
MANAGEMENT: CHF/CHD
• Monitor
– VS, dysrythmias
– I/O: weigh diaper
– Weight OD (fluid retention)
– Facial/peripheral edema
– abN breath sounds
• Maintain
– Semi-Fowler’s, Knee-chest, squatting position
– Neutral thermal environment
– Bed rest, uninterrupted sleep
– Adequate nutritional intake (small, frequent feeding; feed per demand)
– Fluid restriction as ordered
• Administer as ordered
– Cool, humidified O2
– Sedatives
– ACE inhibitors: Captopril (Capoten), Enalapril (Vasotec)
– Digitalis (Lanoxin elixir): 50 mcg/ml with HR deferral
– Diuretics (Furosemide) with BP deferral
• WOF K+ levels (K+ ↓ drug effect, ↓K+ potentiates Digitalis toxicity: bradycardia and
vomiting)
– K+ supplements
DIGITALIS PRECAUTIONS
• Digitalis (Lanoxin elixir): 50 mcg/ml
• N blood level= 0.8- 2 mcg/L
• (+) inotropic ( contractility)
• (-) chronotropic (↓ HR): S/E
• (-) dromotropic (↓ AV conduction)
• Drug overdose: if infant receives more than 50 mcg/dose
• HR deferral: <90 infant; <110 young child; <70 older child
30
aoih0718
Pedia
31
aoih0718
Pedia
RHD: MANAGEMENT
• Bed rest (not strict)
• Avoid contact sports
• Aspirin: anti-inflammatory, analgesic
– Not given to pt with viral infection; at risk of Reye’s Syndrome (encephalopathy with fatty infiltrates
on liver and brain)
• C/S by throat swab
• Prophylactic antibiotics to prevent recurrence
– Pen G IM monthly or Erythromycin (if allergic to Pen G)
– Pen V po or Sulfadiazine po
– Duration is uncertain, usually long-term because pt is at risk of bacterial endocarditis
• Given 1 hr prior to dental, surgical procedure
32
aoih0718
Pedia
RESPIRATORY RATE
Normal Values
AGE RATE/MINUTE
NEWBORN 40-60
1 YR 20-40
2-3 YRS 20-30
5 YRS 20-25
10 YRS 17-22
15 YRS AND ABOVE 12-20
BREATH SOUNDS
SOUNDS CHARACTERISTICS
Vesicular Soft, low-pitched, heard over lung periphery, I>E, N
Broncho-vesicular Soft, medium-pitched, heard over major bronchi, I=E, N
Bronchial Loud high-pitched, heard over trachea, I<E, N
Rhonchi Snoring sound made by air moving through mucus in bronchi, N
Rales Crackles (like cellophane) made by air moving through fluid in alveoli, abN:
denotes pneumonia, which is fluid in alveoli
Expiratory Wheezing Whistling on expiration made by air being pushed through narrowed bronchi,
abN: seen in children with asthma or foreign-body obstruction
Inspiratory Stridor Crowing or roosterlike sound made by air being pulled through a constricted
larynx, abN, seen in infants with respiratory obstruction
Resonance Loud, low tone, percussion sound over normal lung tissue
Hyper-resonance Louder, lower sound than resonance, a percussion sound over hyperinflated lung
tissue
BRONCHIOLITIS/ RSV
• Production of thick, tenacious mucus, due to Respiratory Syncytial Virus (RSV)- via direct contact
• Signs and Symptoms
• Cold/flu-like Sx
• Poor feeding, lethargy, irritability
• RR- Sign of developing RDS
• Nasal flaring and retractions
• Expiratory wheeze and grunt
• Diminished breath sounds
• Management
• Maintain patent airway
• Position: 30-40 degree angle with neck slightly extended to open airway and ↓ pressure on
diaphragm
• Provide cool, humidified O2 as ordered
• WOF dehydration: encourage fluids (via IV if on NPO)
• Isolate the child in single room or with another child with RSV
• Strict handwashing
• Administer meds as ordered:
• Anti-viral: Ribavirin (Virazole) via aerosol by hood, tent, mask or ventilator tubings
• RSV IgIV (RespiGam) or palivizumab (Synagis)
EPIGLOTTITIS
• Emergency of all URTI
• Cx of bronchiolitis
• Bacterial form of croup (S. pneumoniae or H. influenzae type B)
• Sudden/acute onset, usually in winter
• Common among 2-5 years of age
• Signs and Symptoms
• High fever
• Sore, red, inflamed throat
34
aoih0718
Pedia
• (-) cough
• Drooling
• Dysphagia
• Muffled voice
• Inspiratory stridor
• Agitation
• Classic Sign
• Tripod Position: leaning forward with tongue protrusion
• Management
• Avoid tongue depressor, oral thermometer, laryngoscopy, throat swab
• Prepare trache set not ET set
• Place pt inside cool Mist tent or Croupette with high humidification (to reduce airway swelling)
• Give plastic, washable toys
• No toys causing friction→ O2 supports combustion
• Tuck edges properly
• Maintain on NPO
• Don’t restrain the child or force to lie down
• Administer antipyretics and antibiotics as ordered
• Ensure up-to-date Hib conjugate vaccination
PNEUMONIA
• Inflammation of the alveoli
• Causative agents
– Virus
– Mycoplasma
– Bacteria
– Aspiration of foreign substance
• Signs and Symptoms
– Acute onset, fever
– Infant: irritability, lethargy, poor feeding, abrupt fever with seizures, RR distress (air hunger,
tachypnea, cyanosis)
– Older child: HA, chills, abdominal & chest pains
– Hacking, nonproductive cough→ purulent sputum
– ↓ breath sounds or scattered crackles, wheezes
• Management
– Bed rest, lie on affected side (splinting)
– Antimicrobial therapy
– Antipyretic as ordered
– Cool, humidified O2 (cannula, hood, mist tent) as ordered
– Liberal fluids
– Chest physiotherapy and suctioning
– Isolation precautions for Staph or Pneumococcal pneumonia
– Thoracentesis
ASTHMA
• Chronic, inflammatory disease of the airways
• Common causes
– Foods, pollens, dust mites, cockroaches, smoke, animal dander, T changes, respiratory infection,
activity, stress
• Status asthmaticus
– A medical emergency, RR failure and death can ensue
– RR distress despite vigorous treatment
• Signs and Symptoms
– Expiratory wheezing, breathlessness, tachypnea, dyspnea, chest tightness, esp. at night and early
am
– Hacking, nonproductive cough→ frothy, clear gelatinous sputum
– Cyanosis, diaphoresis, retractions
– Chest hyperresonance on chest percussion
– (-) breath sounds with tachypnea: ventilatory failure and asphyxia
• Management
– Eliminate allergens
– Avoid extremes of T and exposure to viral respiratory infection
35
aoih0718
Pedia
BLOOD PRESSURE
• Normal values
• < 1yr: 87-105/ 53-66
• Estimation of Systolic BP (lower limit):
70 mmHg + (2 X age in yrs)
• A fall in 10 mmHg: consider shock
AGE SYSTOLIC DIASTOLIC
Birth (12 hrs, < 1kg) 39-59 16-36
Birth (12 hrs, 3kg) 50-70 25-45
Neonate (96 hrs) 60-90 20-60
Infant (6 mos) 87-105 53-66
Toddler (2 yrs) 95-105 53-66
School age (7 yrs) 97-112 57-71
Adolescent (15 yrs) 112-128 66-80
SKIN
• Acrocyanosis- body pink, extremities blue
• Generalized mottling due to immaturity of the circulatory system
MONGOLIAN SPOTS
• slate-gray or bluish discoloration/patches commonly seen across the sacrum or buttocks
• Due to melanocytes accumulation
• Common among Asians
• Disappears by 1 yr or to school age period
MILIA
• Plugged/unopened sebaceous glands
• White pinpoint patches on nose, chin, cheek
• Disappears by 2-4 wks
LANUGO
• Fine downy hair covering the shoulders, back, upper arm
• Common in preterms
• Disappears in 2 wks
DESQUAMATION
• peeling of the NB skin within 24 hrs
• Common in post terms
• Extreme dryness beginning at soles and palms
STORK BITES
• Or Telangiectasi nevi
• Pink patches at the nape of the neck
• Disappears when child grows
ERYTHEMA TOXICUM
• Or Flea-bite rash
• 1st self-limiting rash
• Appears sporadically and unpredictably as to time and place
HARLEQUIN SIGN
• dependent part is pink, independent part is blue, because of the tendency of RBC to go down
36
aoih0718
Pedia
CUTIS MARMORATA
• Transitory mottling of the skin when exposed to cold
HEMANGIOMAS
• vascular tumors of the skin
• 3 Types
1. Nevus Flammeus (Portwine Stain) -macular purple or dark red lesions usually seen on the face or thigh
• Never disappear, can be removed surgically
2. Nevus vasculosus (Strawberry hemangiomas)- dilated capillaries in the entire dermal or subdermal
area continuing to enlarge but disappear after 10 years old
3. Cavernous hemangiomas- consist of communicating network of venules in the subcutaneous tissue that
never disappear with age
• Most dangerous type, may lead to internal hemorrhage or aneurysm
VERNIX CASEOSA
• White, cheese-like substance for lubrication
• Insulator and bacteriostatic
• If yellow: hyperbilirubinemia
SKIN COLOR’S SIGNIFICANCE
• Blue: cyanosis (hypoxia)
• White: edema
• Pale: anemia
• Yellow: carotenemia or jaundice
• Gray: infection, sepsis
BURN TRAUMA
• injury to body tissue cause by excessive heat
HIGH RISK BURN VICTIM: CHILD
• Higher proportion of body fluid to smaller muscle & fat mass, thinner skin→ Higher mortality r/t
– Fluid & heat loss
– Dehydration
– Metabolic acidosis
– Cardiovascular collapse
– Protein & calorie deficiency
– Infection
5-9 YEARS
PARTS ANTERIOR POSTERIOR
Head 6.5 6.5
Neck 1 1
Upper Arm 2 2
Lower Arm 1.5 1.5
Hand 1.25 1.25
Trunk 13 -
Back 13 -
Genital 1 -
Each Buttock 2.5 -
Thigh 4 4
37
aoih0718
Pedia
Leg 3 3
Foot 1.75 1.75
ASSESSMENT OF DEPTH
• 1ST Degree (Superficial Thickness)
– involves only the superficial epidermis characterized by erythema, dryness and pain
– Example: Sunburn
– Heals by regeneration by 1-10 days
• 2ND Degree (Partial Thickness)
– involves the entire epidermis, and portion of dermis characterized by erythema, blistered and moist
from exudates which is extremely painful
– Example: Scalds
– Heals by regeneration by 4-6 wks
• 3RD Degree (Full Thickness)
– involves both skin layers, epidermis and dermis/may involve adipose tissue, fascia, muscle and
bone
– appears leathery, white or black and not sensitive to pain since nerve endings had been destroyed
– Example: Lava, flame burns
Management
1. First aid
– Put out flames by rolling the child on a blanket
– Immerse the burned part on a cold water
– Remove burned clothing
– Cover burns with sterile dressing
2. Maintenance of a patent airway
– Suction secretions prn
– O2 administration with humidity
– Tracheostomy or ET intubation
3. Prevention of Shock, Fluid and Electrolyte Imbalance
– Isotonic saline or LR to replace electrolytes
– Colloids to expand blood volume
– Dextrose in water to provide calories
ATOPIC DERMATITIS
• Or Infantile eczema (2-6mos. of age)
• Papulovesicular erythematous lesions with weeping or crusting
• Due to food allergens
– Milk, eggs, citrus juices, tomatoes, wheat
• Signs and Symptoms
– Extreme pruritus
– Linear excoriation (due to scratching)
– Lichenification (scaly, shiny white skin)
• Management
– Avoid food allergens
– Give Isomil or Prosobi (hypoallergenic milk)
– Hydrate skin with Burowl’s solution
– Topical steroid (1% hydrocortisone cream)
– Topical antihistamine
38
aoih0718
Pedia
• Skin care: avoid skin irritants (soap, detergent, fabric softener, diaper wipes, powder)
• Apply cool, wet compress to soothe skin
• Proper hygiene: hand washing, nail cutting
• Minimize scratching: place gloves/mittens over hands
• Avoid heat, woolen clothes/blankets, rough fabrics, furry stuffed animals
IMPETIGO
• Highly infectious, caused by Group A β -hemolytic Streptococcus, possibly Staph aureus
• Predisposing factor: heavy infestation of Pediculosis capitis then pick nose
• Papulovesicular lesions (face, around mouth, hands, neck, extremities) surrounded by localized erythema
becoming purulent and ooze, forming a honey-colored crust
• Cx: AGN
• Management
• Contact isolation (Communicable for 48hrs without treatment)
• Skin care
– Allow lesions to dry by air exposure
– Daily bathing with antibacterial soap (pHisoHex)
– Warm compress 2-3X/day to remove crusts
– Use of skin emollients to prevent cracking
• Proper hygiene
– Strict handwashing
– Use separate towels, linens, dishes (washed separately with detergent in hot water)
• Oral antibiotics (Penicillin)
• Antibiotic ointment (Mupirocin)
• Strict handwashing
• Change all clothing & bedding OD, wash in detergent with hot water, hot dryer & iron before reuse
• Seal nonwashable toys & other items in plastic bag for 4 days
ACNE VULGARIS
• Self-limiting, inflammatory skin disease involving sebaceous glands
• Common among adolescents
• Sign: Comedones: composed of sebum (lipids) causing whiteheads
• Management
• Proper hygiene
• Use mild sulfur (antibacterial) soap
• Anti-acne cream (Tretinoin, Retin-A)
HEMOPHILIA
• X-linked recessive
• 3 Types
– Hemophilia A: deficient clotting Factor VIII (classic)
– Hemophilia B: deficient clotting Factor IX (Christmas disease)
– Hemophilia C: deficient clotting Factor XI
Signs and Symptoms
• Sudden bruising when child grows (earliest sign)
– Delayed diagnosis at birth because NB received maternal clotting factors
– Major sign: Hemarthrosis- bleeding/damage to synovial membrane
• abN bleeding in response to trauma or surgery
• N: bleeding time, PT, platelet count; abN: PTT
Management
• Monitor bleeding: hematuria, IC bleed (neuro status)
• Bleeding precautions:
– Avoid contact sports (swimming is preferred) or if anticipated, wear protective devices (helmets,
knee & elbow pads)
– Ask pt if hemophiliac before doing any invasive procedures
– Use smaller gauge needle
• Immobilize and elevate bleeding extremity, apply gentle pressure (15 mins) and cold compress
• Administer factor VIII concentrate or desmopressin (DDAVP) as ordered
LEUKEMIA
• Group of malignant disease
• Rapid immature WBC, competes nutrition with mature WBC and production of RBC and platelets
• N= 500 RBC: 1 WBC
CLASSIFICATION OF LEUKEMIA
• Lympho- affects lymphocytes
• Myelo- affects myeloblasts
40
aoih0718
Pedia
ABO INCOMPATIBILITY
• Happens when:
– Mother blood type O
– Fetus: A, B, AB
• O-A most common
• O-B most severe
• 1st child can be severely affected
42
aoih0718
Pedia
Blood RB
Group A
• Upon uterine contraction: start of hemolysis
• Fetus: Hydrops fetalis
– Edematous, lethal state with pathologic jaundice
• Management
– No breastfeeding
• Has Pregnanediole: delays action of glucoronyl transferase (liver enzyme that converts
indirect to direct bilirubin) otherwise, complication: Kernicterus (irreversible brain death)
• Use of Phototherapy
• Exchange Transfusion for Rh or ABO affectations cause continuous ↓ in Hgb during the first 6 months
because the BM fails to produce erythrocytes in response to continuing hemolysis
JAUNDICE
• Hyperbilirubinemia
– N= 0-3 mg/dl indirect bilirubin
– >12 mg/dl (full terms)
• Kernicterus (Bilirubin Encephalopathy)
– >20 mg/dl (full terms)
– >12 mg/dl (preterms, because liver is immature)
– May lead to cerebral palsy
AB A,
• Physiologic Jaundice (Icterus Neonatorum)
– Onset: 2nd to 7th day of life, for 48-72 hrs
– Management: exposure to early AM sunlight
• Pathologic Jaundice
– Onset: within 24 hrs, for > 1-2 wks
• Breastfeeding Jaundice
– Due to pregnanediole
• Assessment
– Blanching the forehead, nose or sternum
– Normal finding: cyanosis
– Light stool, dark urine, yellow sclerae
• Management: Phototherapy or Photooxidation 18-20 in. far from NB
• Use of intense florescent lights to ↓ serum bilirubin levels
• Injury from treatment e.g. eye damage, dehydration or sensory deprivation can occur
• Cover the eyes (to prevent retinal damage, corneal dryness)
43
aoih0718
Pedia
HEAD
¼ (25%) the entire body length
Structures
Sutures: sagittal, coronal, lambdoidal
Fontanels: 6, 2 are palpable (Anterior and Posterior)
CAPUT SUCCEDANEUM
Edema of the scalp due to prolonged pressure at birth
Present at birth
Crosses suture lines
Disappears after 2-3 days (water absorbed easily)
CEPHALHEMATOMA
Collection of blood due to ruptured periosteal capillaries r/t trauma
Present after 24hrs
Doesn't cross suture lines
Disappears after 4-6 wks (WOF jaundice)
SEBORRHEIC DERMATITIS
Or Cradle Cap
Scaling, greasy-appearing, salmon colored patches usually seen on the scalp, behind ears and umbilicus
Due to improper hygiene
44
aoih0718
Pedia
Mgt: apply coconut/baby oil the night before shampooing the next day
HYDROCEPHALUS
• CSF production > absorption
• Causes
– Malformations
– Tumors
– Hemorrhage
– Infection
– Trauma
• 2 types
– Communicating (Extraventricular) r/t impaired CSF absorption
– Non-communicating (Intraventricular)- r/t CSF flow obstruction
Early Signs and Symptoms
• ↓ LOC
• AbN large head >35 cm (N by 1-2 yrs, HC=CC; measure HC until 2 yrs)
• Bulged/tensed fontanel
• Cracked-pot sound on percussion: Macewen’s sign
• Dilated scalp veins
• Projectile vomiting: surest sign of cerebral irritation
• Frontal Bossing: prominent forehead
• Sunset eyes
• Headache, dizziness, vertigo
• Diplopia
• Change in pupilary response and equality
Late Signs and Symptoms
• High-pitched, shrill cry
• Seizures
• Cushing’s triad: BP with widened pulse pressure, ↓ HR, ↓ RR
• Decorticate and decerebrate posturing
• Fixed and dilated pupils
Management
• Position: low semi-fowler's (head at 30-45 degree angle and at midline)
• Mannitol- osmotic diuretic
• Acetazolamide- to decrease CSF production
• Diazepam/Phenobarbital- anticonvulsants
Surgery
• VP (Ventriculoperitoneal) shunt
– CSF drains into peritoneal cavity from lateral ventricle
• AV (Atrioventricular) shunt
– CSF drains into R atrium from the lateral ventricle
– Used for older children and with pathological conditions of the abdomen
Post-op Management
• Sidelying position on non-operative side to prevent pressure on the shunt valve
• Keep child flat as prescribed to avoid rapid reduction of CSF
• If ICP occurs, elevate head of bed 15-30 degrees to enhance gravity flow to the shunt
• Sign of good drainage: sunken fontanel
• If blocked/obstructed: bulging fontanel
• Shunt is changed as the child grows
• WOF and prevent infection
MENINGITIS
CNS infection caused by bacteria or viruses
May be acquired as a complication of neurosurgery, trauma, infection of the sinus, ears or systemic
infections
Diagnosis: CSF analysis via Lumbar Puncture (LP): insertion of spinal needle thru the L3-L4 interspace
under strict asepsis
Contraindication: ICP→ brain herniation
Preparation: informed consent, pt on empty bladder
Collect and label specimens in sequence
Force fluids post procedure as ordered
Positions:
45
aoih0718
Pedia
During LP: C-position, fetal or shrimp: knees flexed up to abdomen, head bent, chin to
chest
After LP: flat on bed for 4-12 hrs as prescribed
CSF shows pressure, cloudy, CHON, ↓glucose
Signs and Symptoms:
Fever, chills
Vomiting, diarrhea
Anorexia High-pitched cry
Bulging fontanels
↓ LOC
Muscle joint pain
Petechial or purpuric rashes (meningococcal infection)
Kernig’s sign: pain and spasm of hamstring when thigh and knee are flexed
Brudzinki’s sign: head flexion→ knee and hip flexion
Management
Isolation for at least 24hrs after antibiotics are initiated
Administer antibiotic as ordered
Monitor neuro VS, I/O, nutritional status
Determine child’s close contacts for prophylactic treatment
SENSES
Sense of Sight (Eyes)
Sclera
N: bluish-gray, white
AbN: subconjunctival hemorrhage (t/c Shaken Baby Syndrome)
Pupils
N: PERLA, round
AbN: Coloboma- absence of part of iris
AbN: Congenital cataract: Rubella exposure while in utero
Cornea
N: bright, shiny, corneal reflex to touch, (+)blink reflex, round and adult-sized
Retina
abN: Retinoblastoma (tumor)
Mgt: Enucleation
Test for Blindness for Infant and Children
Doll's test:
N: when head is turned, eye movement lags behind
AbN: if beyond 10 days
Glabellars or Myerson's Test:
Tap over forehead, bridge of nose or maxilla
N: blinks for 1st 4-5 taps
Test for Blindness for School age and Adolescents
Tonometry
Snellen's Chart
N: eyes cross because of weak EOMs
N: eyelids edematous r/t pressure during birth & effects of eye meds
Sense of Smell (Nose)
Normal findings (Neonate/Infant)
At midline, appears large for the face
Apparent lack of bridge, flat, broad
Some mucus but (-) discharge
Obligatory nose breathers
Sneezes
Abnormal findings (Neonate/Infant)
Malformed
(+) alar flaring (RDS)
Copious discharge
46
aoih0718
Pedia
With or without cyanosis, return to pink when crying (Congenital syphilis or Chromosomal
disorders)
Sense of Hearing (Ears)
1st sense to develop and last sense to disappear
N: firm cartilage with recoil
N: aligned with outer canthus of eyes
Abnormal finding: LOW-SET EARS
Kidney malformation
Renal Agenesis: unilateral and bilateral (dangerous
Mgt: Kidney transplant
Chromosomal aberration
DEVELOPMENTAL DEFECTS
Multifactorial: disease requiring both genetic predisposition and environmental condition
Ex: Arthritis, DM, HD
Single gene defect
Dominant inheritance
Polydactyly
Huntington's disease (NS degeneration)
Chronic/Simple glaucoma
Recessive inheritance
PKU
Thalassemia
Sickle-cell anemia (Mediterranean Jews)
X-linked
Color blindness
Hemophilia
CHROMOSOMAL ABERRATION
Nondisjunction: uneven division resulting 45 and 47 chromosomes (abN structure and number of
chromosomes)
Trisomy 21 (Down's Syndrome/ Mongolism): most common type
Extra chromosome 21
Karyotype: 47 XX+ 21 or 47 XY+21
Predisposing factor: maternal age >35, paternal age >45
DOWN’S SYNDROME
Signs and Symptoms
Low set ears
Mongolian eyes: slanted eyes
Broad, flat nose
Protruding tongue
Puppy neck
Simean crease: single transverse line on palm
Hypotonia: at risk for URTI
MR: from educable to needing institutionalization
EDWARD’S SYNDROME
Or Trisomy 18
Karyotype: 47 XX+18 or 47XY+18
Signs and Symptoms
Rocker’s Bottomfoot: Sole of foot rounded
Misshapen fingers and toes
PATAU’S SYNDROME
Or Trisomy 13
Karyotype: 47 XX+13 or 47XY+13
Signs and Symptoms
Micropthalmia
47
aoih0718
Pedia
Eye agenesis
TURNER’S SYNDROME
Or Monosomy of X chromosome
Karyotype: 45 XO with vagina
Signs and Symptoms (seen only during puberty)
Poorly developed female secondary sex characteristics
Sterile: Mgt: HRT (Estrogen)
KLINEFELTER’S SYNDROME
Or Trisomy of X chromosome
Karyotype: 47 XXY with penis
Signs and Symptoms (seen only during puberty)
Poorly developed male secondary sex characteristics
Voice not deep, gynecomastia
Sterile: Mgt: administration of androgen
Deletion Abnormalities: part of chromosome breaks during cell division resulting 45 ¾ chromosomes
Cri-du-chat Syndrome: 46 XX5g (5th chromosome in defect)
Fragile X Syndrome
Translocation Abnormalities: normal count of chromosome but structural arrangement is different
Balanced Translocation Carrier
Unbalanced Translocation Syndrome
Mosaicism: a situation wherein the nondisjunction of chromosomes occurs during the mitosis after
fertilization resulting to different cells contains different numbers of chromosome
Some cells are N, some abN
Better prognosis, has no severe mental defect
Associated with teratogens
Isochromosomes: a situation wherein the chromosome instead of dividing vertically it divides horizontally
resulting to chromosomal mismatch
48
aoih0718
Pedia
BELL’S PALSY
• Facial Nerve Paralysis (CN VII Injury) due to forceps delivery
• Self-limiting
• Signs and Symptoms
– Continuous drooling
– Inability to open one eye and close the other eye
• Apply artificial tears
TRACHEOESOPHAGEAL FISTULA/ATRESIA
(-) connection of esophagus to stomach, may have connection to trachea
Aspiration pneumonia, severe RR distress and death may ensue without surgical intervention
A surgical emergency (placement of cervical esophagostomy and gastrostomy tube)
Signs and Symptoms (4C’s)
Coughing
Choking
Cyanosis
Continuous drooling
49
aoih0718
Pedia
EPSTEIN PEARLS
N among NB
1-2, small, round, glistening white cysts seen at the palate or gums r/t hypercalcemia while in utero
NATAL TOOTH
• Rootless, tooth at the moment of birth r/t hypervitaminosis while in utero
• Should be extracted to prevent aspiration
NEONATAL TOOTH
Tooth appearance within 28 days of life
Anodontia: (-) tooth up to 5 yrs
KAWASAKI DISEASE
• Or Mucocutaneous Lymph Node Syndrome
• Acute systemic vasculitis of unknown cause
• Self-limited
• Common among Asians (disease originated in Korea)
• Complications: dilation of coronary arteries→ MI (S/Sx in children: abdominal pain, vomiting, restlessness,
pallor, shock) and aneurysm, damage to heart muscle
• Diagnostic Criteria (Acute Stage)
• Fever > 5 days
• Bilateral Conjunctivitis
• Red throat
• Swelling of cervical lymph node to > 1.5 cm in diameter
• Swollen hands & feet
• Polymorphous rash (primarily on trunk)
• Subacute Stage
• Changes of lips and oral cavity
• dry, red fissure lips
• STRAWBERRY TONGUE
• Changes of peripheral extremities
• Desquamation of the skin from tips of fingers and toes
• Joint pain
• Cardiac manifestations
• Thrombocytosis
• Convalescent Stage
• Child appears normal but signs of inflammation may be present
Three Phases
• Acute: all S/Sx appears, + restlessness for 2 months (hallmark of KD) and arthritis
• Subacute: resolution of all S/Sx, at greatest risk of coronary artery aneurysms (blood vessels
stretch 4 wks post onset) and coronary thrombosis (due to thrombocytosis and hypercoagulability)
• Convalescent: blood values return to N (6-8 wks post onset) e.g. ↓ ESR, ↓ thrombocytosis
Management
• Monitor
• T frequently
• Heart sounds & rhythm
• Extremities for edema, redness & desquamation
• Eyes & mucous membranes for inflammation
• Dietary & fluid intake
• Weight OD
• Passive ROM exercises to facilitate joint movement
• Give soft foods/liquids (not too hot or too cold)
• Administer as ordered
50
aoih0718
Pedia
• High dose IV Immunoglobulin during the 1st 10 days: 2g/kg as 10-12 hr drip (to ↓ incidence of
coronary artery lesions & aneurysms)
• S/E: allergic rxn, extravasation, ↓ production of antibodies (delay MMR vaccine 11 mos. and
chickenpox vaccine 5 mos after IVIG)
• Aspirin
• High dose: 80-100mg/kg/day (in divided dose q6h) antipyretic and antiinflammatory (S/E
toxicity: tinnitus, HA, dizziness, confusion)
• Low dose: 3-5mg/kg/day antiplatelet (S/E easy bruising→ avoid contact sports)
• Warfarin (Coumadin) for children with giant aneurysm (>8 mm)
NECK
N: Short and thick, almost non-existent
Trachea in midline
Thyroid gland not palpable
51
aoih0718
Pedia
CONGENITAL TORTICOLIS
Or Wry neck
Injured sternocleidomastoid muscle
Birth injury r/t excessive traction during cephalic delivery
Mgt: passive neck stretching exercises daily
CONGENITAL CRETINISM
Or Thyroid Dysgenesis
Absence or non functioning thyroid glands
Delayed diagnosis in NB because
Thyroid gland is covered by sternocleidomastoid
Baby received maternal thyroxine
Baby N sleeps 16-20 hrs/day
Signs and Symptoms
Changes in sucking (poor)
Changes in crying (weak)
Sleeps excessively
Constipation
Edema (moon-face)
MR (late sign)
Diagnostic Test
Protein bound I2
Radio immunoassay test
RAIU (RadioActive Iodine Reuptake) test
Treatment
Thyroxine (Synthroid) for lifetime
S/E tachycardia (hyperthyroidism) NI! Check HR prior to giving of meds
CHEST
N: smaller than the head
Circular: AP diameter = 1:1
Temporary breast engorgement with Witch’s milk (thin, watery fluid) r/t effect of maternal hormones
Breathing: diaphragmatic and abdominal
Clavicles intact
GASTROINTESTINAL SYSTEM
Functions:
Assists in maintaining fluid and electrolyte and acid/base balance
Processes and absorbs nutrients to maintain metabolism and support growth and development
Excrete waste products from the digestive processes
SUPPLEMENTAL FEEDING
Principles
52
aoih0718
Pedia
Solid food are offered according to the following sequence: cereals (given as early as 4 mos: start
of iron catabolism, usually given at 6 mos: iron catabolism is complete)→fruits →vegies →meat
→finger foods → table foods
Begin with small amount
Finger foods are offered by 6 mos
Dilute citrus juices offered by 6 mos
Offer new food one at a time, with interval of 4-7 days (to determine food allergy)
Soft table food (modified family menu) offered by 12 mos (baby in high chair)
Avoid giving half-cooked egg → Salmonellosis
Avoid giving honey → Infant Botulism
ACID-BASE IMBALANCE
Respiratory acidosis
Hypoventilation conditions
Apnea
Cystic fibrosis (CO2/air trapping)
Respiratory alkalosis
Hyperventilation conditions
Tachypnea: asthma, RDS
Metabolic acidosis
Chronic diarrhea
Severe hypothermia: NB and infants
Metabolic alkalosis
Chronic vomiting
Prolonged suctioning of GI contents
GI post-op (bowel obstruction)
NGT NPO to suction to decompress stomach
VOMITING
Forceful ejection of gastric contents thru the mouth
Usually self-limiting, no specific tx unless Cx occurs
Signs and Symptoms and Causes
Vom+T+ diarrhea= GI infection
Vom+constipation= GI obstruction
Signs and Symptoms and Causes
Vom+localized abdominal pain= appendicitis, pancreatitis, peptic ulcer
Vom+↓LOC+HA= CNS or metabolic disorders
Projectile vom=pyloric stenosis, ICP
Others: toxic ingestion, food intolerance/allergy, psychogenic disorders
Assessment of color and consistency
Green/bilous= bowel obstruction
Curdled, mucus or fatty foods several hrs post ingestion= poor gastric emptying or high intestinal
obstruction
Management: tx underlying cause
B-anana not given to pt with
R-ice diarrhea; ↓ energy
A-pplesauce electrolytes and CHON
T-oast CHO (osmolality)
Nursing Management
Upright positioning during feeding to prevent aspiration
Oral care post vomiting
Liberal fluids with CHO to spare body protein and prevent ketosis
53
aoih0718
Pedia
DIARRHEA
in stool frequency (>3-5x/day) with water content
2 Types
Acute diarrhea
CNSD (Chronic Non-Specific Diarrhea)
Associated with
Gastroenteritis: bacteria, virus, fungi
Dietary causes: overfeeding, excess sugar in formula, intro of new foods
Meds: laxatives and antibiotics
Amox, Ampi, Pen
Poisoning: Arsenic, Lead, Mercury, Organophosphate
CNSD
Or Irritable Colon of Childhood or Toddler’s Diarrhea
Associated with
Food (Lactose) intolerance
Excessive softdrinks/ fruit juices: sorbitol and fructose
↓ fat diet: restricted dairy and milk products
*osmotically active, CHO, ↓ e+
Associated with contaminated water
2 wks duration, no S/Sx of malnutirition, enteric infection and dehydration
rate of gastric emptying and intestinal transit time
ASSESSMENT
u.o., ↓ weight, (-) tears, (-) saliva, dry mucous membranes, poor skin turgor, sunken fontanel, pale cool dry
skin
Severe DHN: ↓BP, HR, RR, >2sec CRT (impending shock)
COMPLICATIONS
1. Dehydration
Mild: 5-6%, thirst, slighty dry buccal mucosa
Moderate: 7-9%, (-) skin turgor, sunken eyes and fontanel
Severe:>9%, S/ of moderate DHN + one of the following
Rapid, thready pulse
RR
Lethargy to coma
Severe metabolic acidosis
2. Electrolyte Imbalance
Metabolic acidosis (H+)
Respiratory alkalosis
3. Malnutrition
Due to ↓ dietary intake, malabsorption syndrome and catabolic response to infection
MANAGEMENT
Oral Rehydration Solution (ORS): Pedialyte, Hydrite, Infalyte, WHO), rice-based ORS as substitute
Tx of choice for mild to mod DHN
Physiologic basis: glucose-mediated solution Na+ absorption
Most effective, less painful, less costly than IV
Replace stool losses with ½-1 cup ORS
IV (plain LR or D5NSS)
For severe DHN with shock: 20-30 cc/kg bolus
Anti-diarrheal meds (Lomotil, Imodium) not recommended: worsen diarrhea→toxicity and ADR due to ↓
motility, ileus may occur
NURSING CARE
Assess hydration status, weigh OD, I/O, urine specific gravity
Continue breastfeeding and usual diet
Skin care on perianal area (Zinc oxide cream)
No rectal T!: stimulate bowel and stool passage
Hand washing, proper disposal of diapers
54
aoih0718
Pedia
HIRSCHSPRUNG’S DISEASE
Or Congenital Megacolon or Aganglionosis
(-) of ganglion cells in rectum & upward colon (for peristalsis)→ mechanical obstruction
Cx: Enterocolitis (fever, GI bleeding, explosive watery diarrhea)
Assessment in Newborn
Failure to pass meconium within 24 hrs
Abdominal distention
Foul-odor of breath/vomitus of bile/fecal material
Assessment in Children
Poor weight gain & delayed growth
Ribbon-like & Foul-smelling stool
Vomiting
Constipation alternating with diarrhea
Diagnostic Tests
Barium Enema — reveals the narrowed portion of the bowel
Rectal Biopsy – (-) ganglion cells
Abdominal x-ray – reveals dilated loops on intestine
Rectal manometry – reveals failure of intestinal sphincter to relax
Management
Diet, stool softeners, daily rectal irrigation with pNSS
2-stage Surgery
1. Temporary colostomy
Diet: CHON, calories, ↓ residue (can cause obstruction)
2. Trans-anal anastomosis and pull-through & closure of colostomy
Pre-op Management
Maintain NPO status
Monitor
Bowel functions
Hydration & electrolyte status
Weight, I/O
Abdominal girth
RR distress
Avoid taking rectal temp!
Administer as ordered
IV fluids
Antibiotics
Bowel prep
Post-op Management
Maintain
NPO status until bowel sounds return (48-72hrs)
IV fluids until progressive oral intake is tolerated
Assess
Stoma (should be pink & moist) for bleeding, skin breakdown, provide colostomy care
Surgical site for redness, swelling & drainage
Anal area for stool, redness, drainage
Administer Analgesics, Antipyretics, Antibiotics as ordered
PYLORIC STENOSIS
Hypertrophy of circular muscles of pylorus → narrowing & obstruction
Signs and Symptoms
Projectile vomiting after feeding
Vomitus: gastric contents, with mucus or blood, no bile
Hunger, irritability
Olive-shaped mass at RUQ
Peristaltic waves visible from left to right across epigastrium during or after feeding
Metabolic alkalosis, electrolyte imbalance
Dehydration, malnutrition
Diagnostic Tests
ABG: metabolic alkalosis
Serum electrolyte: Na and K, ↓ chloride
Ultrasound: confirms diagnosis
X-ray of upper abdomen with barium swallow (reveals tinged sign)
Management
Pyloromyotomy (incision through the muscle of pylorus, done under laparoscopy)
INTUSUSSCEPTION
Telescoping or invagination of one part of the bowel to another portion
Most common site: ileoceccal junction → inflammation → necrosis → PERITONITIS (ER of GIT; persistent
abdominal pain) → perforation & shock
Assessment
Currant-jelly stools (due to inflammation and bleeding)
Palpable sausage-shaped mass at RUQ
Abdominal distention & pain
Bile-stained fecal vomitus
56
aoih0718
Pedia
GASTROSCHISIS
Hernia of intestine lateral to the umbilical ring, no membrane covers the exposed bowel
Cover exposed bowel with LOOSE sterile gauze soaked with pNSS then with plastic wrap to prevent drying,
pressure & necrosis
Emergency surgical repair needed
Maintain on NPO, IV fluids/TPN, prevent hypothermia & infection
GALACTOSEMIA
Inborn error of CHO metabolism
Deficient Galactose-1 Phosphate Uridine Transferase needed for conversion of galactose to glucose
Damages liver, spleen, brain and eyes (cataract)
Assessment
NB appears to be N at birth but after milk ingestion ( lactose) vomit →lose weight → malnourished
Death during 1st mo of life occurs if infant is untreated
Management
Eliminate all milk and lactose-containing foods (even breast milk)
Use lactose-free formula (Soy protein formula)
Gene replacement therapy (very expensive)
57
aoih0718
Pedia
APPENDICITIS
Inflammation of appendix
Perforation may occur in a matter of hours→ peritonitis & sepsis
Treatment: appendectomy before perforation occurs
Signs and Symtpoms
Pain: periumbilical area descends to RLQ, most intense at McBurney’s point
Rebound tenderness & abdominal rigidity
WBC, low grade fever
A/N/V, diarrhea
Side-lying position with abdominal guarding (legs flexed)
Sudden relief of pain then becomes intense
fever, HR, RR
Progressive abdominal distention
Pallor, chills
Restlessness, irritability
Pre-op Management
Maintain NPO
Promote comfort
R sidelying or semi-Fowler’s position
Abdominal ice packs q 20-30mins hourly
Monitor
Changes in pain level
Bowel sounds
Avoid
Heat application
Rectal exam, thermometer, enema, laxatives
Administer as ordered
IV fluids
Antibiotics
Post-op Management
Maintain NPO, maintain NGT suction
R sidelying or semi-Fowler’s position to keep Penrose drain patent
Monitor for
T, redness, swelling pain at site (infection)
Presence of bowel sounds (to start feeding)
Administer as ordered
Antibiotics
Analgesics
POISONING
Common among toddlers
Principles
Determine the substance taken
Unless the poison was corrosive, caustic (strong alkali such as LYE) or a hydrocarbon, vomiting is
the most effective way to remove the poison from the body
Principles
Syrup of Ipecac- oral emetic to cause vomiting after drug over dose or poisoning
15 ml to adolescent, school age and pre-school
10 ml to infant
Can give up to 2nd dose if don’t vomit after 1st dose
Universal antidote - charcoal, milk of magnesia, and burned toast
Never administer the charcoal before ipecac
Antidote for Acetaminophen poisoning: Acetylsysteine (Mucomyst) to prevent liver damage
For caustic poisoning:
58
aoih0718
Pedia
ACETAMAINOPHEN POISONING
Toxic dose: >150mg/kg
Signs & Symptoms
1st 2-4hrs: malaise, N/V, sweating, pallor, weakness
Latent period 24-36hrs: child improves
Hepatic involvement: up to 7days & may be permanent; RUQ pain, jaundice, confusion, stupor,
liver enzymes, bilirubin, Pro time
Management: N-Acetylcysteine (Antidote)
Dilute in juice/soda to remove offensive odor
ASPIRIN POISONING
Toxic dose: Acute ingestion: 300-500mg/kg
Chronic ingestion:>100mg/kg/day X2days or more
Signs & Symptoms
N/V, thirst, hypoglycemia, ↓Na+, ↓K+, diaphoresis, oliguria, bleeding, dehydration, fever
Hyperpnea, confusion, tinnitus, seizure, coma, respiratory & circulatory failure
Management
Syrup of Ipecac, gastric lavage with activated charcoal
Administer as ordered: IVF, NaHCO3, electrolytes, volume expander, glucose, Vit. K
Prepare for dialysis if unresponsive to the therapy
ANOGENITAL AREA
Both sexes: foul-smelling urine (Urethroanal fistula)
Female
N in NB:
Labia edematous, clitoris enlarged
Pseudomenstruation
Hymen tag may be visible
1st voiding within 24 hrs
N in adolescents: inverted triangle shape of pubic hair
Preschool: thinning of fourchet (rape/child abuse)
Bruises: identical (e.g. cigarette butts), of different stages
Report within 48 hrs
Keep child in safe environment
59
aoih0718
Pedia
RENAL DISORDER:
NEPHROTIC SYNDROME
Cause Assessment Findings Treatment Nursing Care
Infectious Hypoalbuminemia, anasarca, Corticosteroid Monitor VS, I/O, urine SG,
massive proteinuria, (Prednisone) albumin, edema
microscopic or (-) hematuria,↓ Immuno-suppresant Weigh OD (same time, clothing,
serum CHON, serum lipid, N Diuretics scale)
or ↓ BP Plasma expander Assess for DHN
(salt-poor human Diet: CHON, ↓ Na+
albumin) WOF infection
AGN
Cause Assessment Findings Treatment Nursing Care
Non-infectious Primary edema, Antihyper-tensives Monitor BP, neuro status, wt,
Auto-immune Peripheral edema, Hydralazine I/O, seizures
Group A Beta Periorbital edema in am, ↓ u.o., (Apresoline) Diet: ↓ Na+, ↓ K+, ↓CHON in
Strep throat 2- mod. Proteinuria, gross Diuretic severe azotemia, Fe
3 wks before hematuria (smoky urine, Cx: Antibiotics WOF Cx: Hypertensive
Sx anemia), fatigue, serum K+, − Fe infusion Encephalopathy, RF, pulm.
Hx: impetigo BUN Crea, ASO titer, BP edema, HF
BACK
N: on prone appears flat, curves start to form when child has learned how to sit or stand
Spine straight
SPINA BIFIDA
CNS defect as a result of neural tube defect during embryonic development
Associated deficits:
Sensory motor disturbance
Hip dislocation
Clubfoot
Hydrocephalus
SPINA OCCULTA
Congenital malformation of the spine
Posterior portion of the vertebrae fails to close
60
aoih0718
Pedia
SCOLIOSIS
• Lateral curvature of the spine
• Most common during the growth spurt, early adolescent stage
• F>M
Assessment
• visible curve fails to straighten when the child bends forward and hangs arms down toward feet (Adam’s
position)
• Asymmetrical shoulder height, scapula and flank shape
• rib prominence and rib humps
• Screening begins at 8 yrs
Management
• Milwaukee Brace- worn between 16-23 hrs/day
– Not curative, but preventive: Slows/Halts progression of the curvature when child reaches skeletal
maturity
– Inspect the skin for signs of redness or breakdown
– Keep the skin clean and dry, avoid lotions and powders
– Advise the child to wear soft, nonirritating clothing under the brace
• Supplemental exercises: to prevent atrophy of spinal and abdominal muscles
• Support in coping: Adolescents may modify lifestyle, may feel stigmatized from peers by being “different”
• Surgery: Internal Fixation and Instrumentation combined with Spinal arthrodesis (fusion)
• Logroll when turning, to maintain alignment post-op
• Assess extremities for neurovascular status
• Promote coughing & DBE, incentive spirometry
• Give pain meds as ordered
• WOF vomiting, abdominal distention: Superior Mesenteric Artery syndrome r/t mechanical changes
in position of abdominal contents during surgery
• Prepare child in using molded plastic jacket during activity
EXTREMITIES
• N in state of flexion
61
aoih0718
Pedia
TALIPES
• Or Club Foot; congenital malformation of LE, uni- or bilateral; defect is rigid & cannot be manipulated into a
neutral position
• Types
• Equinos – Plantar flexion or Horsefoot
• Calcaneous or Dorsiflexion – the heel is held lower than the foot/the anterior portion of
foot is flexed towards the anterior leg
• Varus – foot turns in
• Valgus – foot turns out
• Management
• Treatment begins as soon after birth
• Serial manipulation & casting weekly for 3-6 months, otherwise surgery
• Cast care
FRACTURE
62
aoih0718
Pedia
• Break in the continuity of the bone due to trauma, twisting or bone decalcification
• In children: r/t mobility, immature motor & cognitive skills
• In infants: rare, r/o child abuse
Signs and Symptoms
• Pain or tenderness on affected area
• Loss of function
• Obvious deformity
• Ecchymosis
• Edema
• Muscle spasm
Management
• Assess extent of injury, immobilize affected extremity
• In compound fracture, splint extremity, cover wound with sterile dressing
• Reduction: restoring bone to proper alignment
• Closed: manual alignment followed by immobilization
• Open: surgical insertion of internal fixator (rods, wires, pins)
• Use of cast & traction
CAST
• Function:
– For immobilization
– Maintains bone alignment
– Prevents muscle spasm
• Materials
– Gypsum (CaSO4 crystals)
– Stockinette: prevents irritation
– Lead pencil: to mark area
– Basin of water
• Warm: slows setting process
• Cold: hastens setting process
Nursing Care
• Priority: Neurovascular Check
– C-irculation
– M-otion
– S-ensation
• WOF S/Sx Impaired Circulation (Mgt: bivalving)
– B-lueness/ Coldness
– L-ack of distal peripheral pulse
– E-dema not corrected by elevation
– P-ain on casted extremity
– T-ingling sensation (refer asap!)
• Use open palm to prevent indentation
• Support cast with soft pillow
• May use blower: low, cool setting to dry
• Mark area with bleeding with a pen
• Don’t put anything inside the cast
CRUTCHES
• Purpose
– For support
– To maintain balance
• Use the palms: prior to use- do palm exercises using squeeze ball (to strengthen hand grip)
• The distance between the axilla and the arm piece on the crutches should be at least 3 fingerwidths below
the axilla
• The elbows should be slightly flexed, 30 degrees
• When ambulating with the client, stand on the affected side
• Crutch stance: tripod (triangle) position (6-10 inches in front and to the side)
• Never to rest the axilla on the axillary bars
• Look up and outward when ambulating
• Stop ambulation if numbness or tingling in the hands or arms occurs
CRUTCH GAITS
• Swing through and Swing to: if weight-bearing is not allowed in 2 LE
• 3-point gait: if weight-bearing is allowed in 1 LE
63
aoih0718
Pedia
TRACTION
mechanism by which a steady pull is placed on a part or parts of the body
Used to reduce dislocation and immobilize fractures
PRINCIPLES OF TRACTION
The client should be in dorsal or supine position
For every traction there is always a counter traction.
Line of pull should be in line with deformity
For traction to be effective it must continuous
2 TYPES OF TRACTION
Skin traction
Application of wide band of moleskin, adhesive, or commercially available devices directly to the skin and
attaching weights to them
1. Buck’s extension
• Exerts straight pull on the affected extremity; to immobilize the leg in patient with a fractured hip
• Has a horizontal weight
• Turn towards unaffected side
• Check for pressure sore at the heel of the foot*
2. Russell traction
• Knee is suspended in a sling attached to a rope and pulley on a Balkan frame, creating upward (double)pull
from the knee
• Weights are attached to the foot of the bed
• Used to treat fracture of the femur
• Allows patient to move about in bed more freely and permits bending of the knee joint
• Assess back of the knee for pressure sores
3. Bryant’s traction
• Both legs raised 90 angle to bed
• Used for children under 3 years and 30 lbs to treat fractures of the femur and hip dislocation
• Buttocks must be slightly off mattress
• Knees slightly flexed
3. Pelvic traction
– Pelvic girdle with extension straps attached to ropes and weights
– used for low back to reduce muscle spasm and maintain alignment
Skeletal Traction
• Traction applied directly to the bones using pins, wires, or tongs (Crutchfield) that are surgically inserted,
used for fractures femur, tibia, humerus, cervical spine
COMMUNICABLE DISEASES
MEASLES (RUBEOLA)
Agent: Paramyxovirus
Incubation period: 10-20 days
Communicable period: 4days before to 5days after rash appears
Source: respiratory tract secretions, blood, urine
MOT: airborne, direct contact with droplets
Signs and Symptoms
Fever, malaise, cough
Stimson’s eye (conjunctivitis), puffy eyelids, mucopurulent d/c, photophobia
Stomatitis
Maculopapular rash begins at behind ears spreads down to feet, dries & peels off
64
aoih0718
Pedia
Koplik spots: small, red spots with bluish white center at oral mucosa X3days
Management
Respiratory isolation, Bed rest
Cool mist vaporizer for cough
Eye care, Dim lights for photophobia
Ear care, WOF otitis media
Oral care, Nystatin (antifungal) swish & swallow
Skin care, Calamine lotion (Caladryl)
TSB, Antipyretics for fever
Vit A 200,000 IU (<6y/o) to maintain healthy eyes, skin, prevent pneumonia & diarrhea
MUMPS
Agent: Paramyxovirus
Incubation period: 14-21 days
Communicable period: immediately before & after swelling begins
Source: saliva, urine
MOT: direct contact with droplets
Signs and Symptoms
Fever, HA, malaise
Anorexia
Earache esp. when chewing
Parotid gland swelling
Orchitis
Management
Respiratory isolation, bedrest
Avoid food that require chewing
Hot or cold compress at neck
To relieve orchitis, apply warmth & local support with tight-fitting underpants
CHICKENPOX (VARICELLA)
Agent: Varicella-zoster virus
Incubation period: 13-17 days
Communicable period: 1-2days before & up to 6days after crusting begins
Source: respiratory tract secretions, skin lesions
MOT: direct contact with droplets
Signs and Symptoms
Low grade fever, malaise
Maculopustular rash becoming crusts, begins on trunk and scalp and spreads to extremities
Management
Contact and Airborne isolation
At home, isolate child until vesicles have dried
65
aoih0718
Pedia
Supportive care
DIPHTHERIA
Agent: Corynebacterium diphtheriae
Incubation period: 2-5 days
Communicable period: after 3 (-) cultures, usually 2-4 weeks
Source: nasopharyngeal secretions
MOT: direct contact
Signs and Symptoms
Low grade fever, malaise, sore throat
Foul-smelling, mucopurulent nasal d/c
Gray membrane on tonsils & pharynx
Lymphadenitis (neck edema)
Management
Contact isolation
Bed rest
Administer as ordered
Antibiotics
Antitoxin after skin test to r/o sensitivity to horse serum
TETANUS (LOCKJAW/TRISMUS)
Agent: Clostridium tetani (anaerobic, non-motile, spore forming)
Vegetative, active form releases
Tetanolysin- RBC hemolysis
Tetanospasmin- tonic type of seizures
Source: soil, gut of herbivorous animals
MOT: direct contact
Newborn: via umbilical cord
Children: via dental caries
Adult: via wound
Signs and Symptoms
Lockjaw
Risus sardonicus (Sardonic smile/grin)
Opisthotonos
Intermittent muscular spasms with stimulation
Boardlike abdomen
Extension of extremities
Diaphoresis
Low-grade fever
Management
Prevent spasm stimulation (note duration & freq.)
Exteroceptive: noise (ear plugs)
Proprioceptive: touch (no IM, TSB, no restraints, minimal handling)
Interoceptive: phlegm expectoration
66
aoih0718
Pedia
POLIOMYELITIS
Agent: enteroviruses
Incubation period: 7-14 days
Communicable period: shortly after infection, 1 week in throat, 4-6 weeks in the feces
Source: oropharyngeal secretions & feces
MOT: direct contact, fecal-oral route
Signs and Symptoms
Fever, malaise, A/N, HA, sore throat
Abdominal pain
Soreness, stiffness of trunk, neck & limbs
Flaccid paralysis
Management
Enteric precautions, bed rest
Supportive treatment
WOF respiratory paralysis
Physical therapy
67
aoih0718
Pedia
Question/Answer/Rationale
Set 01
1. Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after
surgery, the nurse should expect the use of:
a. Diuretics
b. Antihypertensive
c. Steroids
d. Anticonvulsants
C. Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema.
2. Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel
should:
A. The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain
blood volume.
3. Nurse Maureen knows that the positive diagnosis for HIV infection is made based on which of the following:
. B. These tests confirm the presence of HIV antibodies that occur in response to the presence of the human
immunodeficiency virus (HIV).
4. Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an adequate amount of high-
biologic-value protein when the food the client selected from the menu was:
a. Raw carrots
b. Apple juice
d. Cottage cheese
. D. One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6
g of carbohydrate. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life.
5. Kenneth who has diagnosed with uremic syndrome has the potential to develop complications. Which among the following
complications should the nurse anticipates:
c. Hypotension
d. Hypokalemia
. A. Elevation of uremic waste products causes irritation of the nerves, resulting in flapping hand tremors.
6. A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be:
c. Perineal edema
d. Urethral discharge
B. This indicates that the bladder is distended with urine, therefore palpable.
7. A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and painful. The nurse
should:
8. Nurse hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An
increased myoglobin level suggests which of the following?
69
aoih0718
Pedia
a. Liver disease
b. Myocardial damage
c. Hypertension
d. Cancer
. B. Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.
9. Nurse Maureen would expect the a client with mitral stenosis would demonstrate symptoms associated with congestion in the:
a. Right atrium
c. Aorta
d. Pulmonary
D. When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because
there is no valve to prevent back ward flow into the pulmonary vein, the pulmonary circulation is under pressure.
10. A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:
d. Pain
A. Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not
experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes
it so difficult to treat.
11. Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including:
b. stomach cramps
c. headache
d. shortness of breath
C. Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache,
hypotension and dizziness.
12. The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?
. A. An increased in LDL cholesterol concentration has been documented at risk factor for the development of
atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels.
13. Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm?
D. There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may
be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery.
14. Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12?
a. dairy products
b. vegetables
c. Grains
d. Broccoli
15. Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions?
a. Bowel function
b. Peripheral sensation
c. Bleeding tendencies
C. Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk
for bruising and bleeding tendencies.
16. Lydia is scheduled for elective splenectomy. Before the clients goes to surgery, the nurse in charge final assessment would be:
a. signed consent
b. vital signs
c. name band
d. empty bladder
B. An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs
are the final check that must be completed before the client leaves the room so that continuity of care and
assessment is provided for.
17. What is the peak age range in acquiring acute lymphocytic leukemia (ALL)?
a. 4 to 12 years.
71
aoih0718
Pedia
b. 20 to 30 years
c. 40 to 50 years
d. 60 60 70 years
A. The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age.
18. Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical manifestations may indicate all of the
following except
a. effects of radiation
c. meningeal irritation
d. gastric distension
. D. Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous system, and
clients experience headaches and vomiting from meningeal irritation.
19. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is contraindicated with
the client?
a. Administering Heparin
b. Administering Coumadin
B. Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin.
20. Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate?
. A. Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine
output should be consistently greater than 30 to 35 mL/hr.
21. Which of the following signs and symptoms would Nurse Maureen include in teaching plan as an early manifestation of laryngeal
cancer?
a. Stomatitis
b. Airway obstruction
c. Hoarseness
d. Dysphagia
72
aoih0718
Pedia
. C. Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be
evaluated because it is one of the most common warning signs.
22. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is
effective because it:
. C. Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the
acetylcholine receptors at the neuromuscular junction.
23. A female client is receiving IV Mannitol. An assessment specific to safe administration of the said drug is:
b. Weighing daily
C. The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it
increases the intravascular volume that must be filtered and excreted by the kidney.
24. Patricia a 20 year old college student with diabetes mellitus requests additional information about the advantages of using a pen
like insulin delivery devices. The nurse explains that the advantages of these devices over syringes includes:
A. These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by
young people because the medication can be administered discreetly.
25. A male client’s left tibia was fractured in an automobile accident, and a cast is applied. To assess for damage to major blood
vessels from the fracture tibia, the nurse in charge should monitor the client for:
. C. Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack of blood
supply to the extremity.
26. After a long leg cast is removed, the male client should:
73
aoih0718
Pedia
27. While performing a physical assessment of a male client with gout of the great toe, Nurse Vivian should assess for additional
tophi (urate deposits) on the:
a. Buttocks
b. Ears
c. Face
d. Abdomen
B. Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow is least active,
including cartilaginous tissue such as the ears.
28. Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places
weight on the:
c. Axillary regions
B. The palms should bear the client’s weight to avoid damage to the nerves in the axilla.
29. Mang Jose with rheumatoid arthritis states, “the only time I am without pain is when I lie in bed perfectly still”. During the
convalescent stage, the nurse in charge with Mang Jose should encourage:
. A. Active exercises, alternating extension, flexion, abduction, and adduction, mobilize exudates in the joints relieves
stiffness and pain.
30. A male client has undergone spinal surgery, the nurse should:
74
aoih0718
Pedia
. C. Alteration in sensation and circulation indicates damage to the spinal cord, if these occurs notify physician
immediately.
31. Marina with acute renal failure moves into the diuretic phase after one week of therapy. During this phase the client must be
assessed for signs of developing:
a. Hypovolemia
b. renal failure
c. metabolic acidosis
d. hyperkalemia
. A. In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily, hypovolemia
may occur and fluids should be replaced.
32. Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests
differentiates mucus from cerebrospinal fluid (CSF)?
a. Protein
b. Specific gravity
c. Glucose
d. Microorganism
. C. The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to
determine whether a body fluid is a mucus or a CSF. A CSF normally contains glucose.
33. A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, “What caused me to
have a seizure? Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the
20 years?
a. Electrolyte imbalance
b. Head trauma
c. Epilepsy
d. Congenital defect
. B. Trauma is one of the primary cause of brain damage and seizure activity in adults. Other common causes of seizure
activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease.
34. What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA?
b. cholesterol level
c. Echocardiogram
d. Bowel sounds
. A. It is crucial to monitor the pupil size and papillary response to indicate changes around the cranial nerves.
75
aoih0718
Pedia
35. Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Which of the following
instruction is most appropriate?
a. “Practice using the mechanical aids that you will need when future disabilities arise”.
d. “You will need to accept the necessity for a quiet and inactive lifestyle”.
. C. The nurse most positive approach is to encourage the client with multiple sclerosis to stay active, use stress
reduction techniques and avoid fatigue because it is important to support the immune system while remaining active.
36. The nurse is aware the early indicator of hypoxia in the unconscious client is:
a. Cyanosis
b. Increased respirations
c. Hypertension
d. Restlessness
. D. Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in unconscious client who suddenly
becomes restless.
37. A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which of the following?
a. Normal
b. Atonic
c. Spastic
d. Uncontrolled
B. In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is catheterized.
a. Progression stage
b. Initiation stage
c. Regression stage
d. Promotion stage
. A. Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing
tumor that cannot be reversed.
39. Among the following components thorough pain assessment, which is the most significant?
a. Effect
b. Cause
c. Causing factors
76
aoih0718
Pedia
d. Intensity
D. Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment.
40. A 65 year old female is experiencing flare up of pruritus. Which of the client’s action could aggravate the cause of flare ups?
B. The use of fragrant soap is very drying to skin hence causing the pruritus.
41. Atropine sulfate (Atropine) is contraindicated in all but one of the following client?
C. Atropine sulfate is contraindicated with glaucoma patients because it increases intraocular pressure.
42. Among the following clients, which among them is high risk for potential hazards from the surgical experience?
a. 67-year-old client
b. 49-year-old client
c. 33-year-old client
d. 15-year-old clien
A. A 67 year old client is greater risk because the older adult client is more likely to have a less-effective immune system.
43. Nurse Jon assesses vital signs on a client undergone epidural anesthesia. Which of the following would the nurse assess next?
a. Headache
b. Bladder distension
c. Dizziness
. B. The last area to return sensation is in the perineal area, and the nurse in charge should monitor the client for
distended bladder.
44. Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Meniere’s
disease except:
a. Antiemetics
77
aoih0718
Pedia
b. Diuretics
c. Antihistamines
d. Glucocorticoids
D. Tracheostomy tube has several potential complications including bleeding, infection and laryngeal nerve damage.
46. Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:
. C. In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The
substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.
47. An 83-year-old woman has several ecchymotic areas on her right arm. The bruises are probably caused by:
d. elder abuse
A. Aging process involves increased capillary fragility and permeability. Older adults have a decreased amount of
subcutaneous fat and cause an increased incidence of bruise like lesions caused by collection of extravascular blood
in loosely structured dermis.
48. Nurse Anna is aware that early adaptation of client with renal carcinoma is:
b. flank pain
c. weight gain
d. intermittent hematuria
. D. Intermittent pain is the classic sign of renal carcinoma. It is primarily due to capillary erosion by the cancerous
growth.
78
aoih0718
Pedia
49. A male client with tuberculosis asks Nurse Brian how long the chemotherapy must be continued. Nurse Brian’s accurate reply
would be:
a. 1 to 3 weeks
b. 6 to 12 months
c. 3 to 5 months
B. Tubercle bacillus is a drug resistant organism and takes a long time to be eradicated. Usually a combination of three
drugs is used for minimum of 6 months and at least six months beyond culture conversion.
50. A client has undergone laryngectomy. The immediate nursing priority would be:
79
aoih0718
Pedia
Set 02
1. Mrs. Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when
listening to client’s lungs indicative of chronic heart failure would be:
a. Stridor
b. Crackles
c. Wheezes
d. Friction rubs
B. Left sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters
alveolar spaces and causes crackling sounds at the end of inspiration
2. Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that
morphine:
B. Morphine is a central nervous system depressant used to relieve the pain associated with myocardial
infarction, it also decreases apprehension and prevents cardiogenic shock
3. Which of the following should the nurse teach the client about the signs of digitalis toxicity?
a. Increased appetite
D. Seeing yellow spots and colored vision are common symptoms of digitalis toxicity
80
aoih0718
Pedia
4. Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help…
C. When diuretics are taken in the morning, client will void frequently during daytime and will not need to void
frequently at night
5. What would be the primary goal of therapy for a client with pulmonary edema and heart failure?
a. Enhance comfort
B. The primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output.
Pulmonary edema is an acute medical emergency requiring immediate intervention.
6. Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is a
characteristic of this type of posturing?
C. Decerebrate posturing is the extension of the extremities after a stimulus which may occur with upper brain
stem injury
7. A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following maybe experienced as side effects of
this medication:
a. GI bleeding
c. Abdominal cramps
C. The most frequent side effects of Cascara Sagrada (Laxative) is abdominal cramps and nausea.
8. Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the
following is the most essential nursing action?
D. Administration of Intravenous Nitroglycerin infusion requires pump for accurate control of medication
9. During the second day of hospitalization of the client after a Myocardial Infarction. Which of the following is an expected
outcome?
A. By the 2nd day of hospitalization after suffering a Myocardial Infarction, Clients are able to perform care without
chest pain
10. A 68 year old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse
should plan to:
b. Use hand roll and extend the left upper extremity on a pillow to prevent contractions
B. The left side of the body will be affected in a right-sided brain attack.
11. Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza’s highest
priority would be…
b. Temperature
A. After nephrectomy, it is necessary to measure urine output hourly. This is done to assess the effectiveness of
the remaining kidney also to detect renal failure early
12. A 64 year old male client with a long history of cardiovascular problem including hypertension and angina is to be scheduled for
cardiac catheterization. During pre cardiac catheterization teaching, Nurse Cherry should inform the client that the primary
purpose of the procedure is…..
82
aoih0718
Pedia
B. The lumen of the arteries can be assessed by cardiac catheterization. Angina is usually caused by narrowing
of the coronary arteries
13. During the first several hours after a cardiac catheterization, it would be most essential for nurse Cherry to…
C. Blood pressure is monitored to detect hypotension which may indicate shock or hemorrhage. Apical pulse is taken
to detect dysrhythmias related to cardiac irritability.
14. Kate who has undergone mitral valve replacement suddenly experiences continuous bleeding from the surgical incision during
postoperative period. Which of the following pharmaceutical agents should Nurse Aiza prepare to administer to Kate?
a. Protamine Sulfate
b. Quinidine Sulfate
c. Vitamin C
d. Coumadin
A. Protamine Sulfate is used to prevent continuous bleeding in client who has undergone open heart surgery.
15. In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in client with mitral
stenosis in teaching plan should include proper use of…
a. Dental floss
b. Electric toothbrush
c. Manual toothbrush
d. Irrigation device
C. The use of electronic toothbrush, irrigation device or dental floss may cause bleeding of gums, allowing bacteria to
enter and increasing the risk of endocarditis.
16. Among the following signs and symptoms, which would most likely be present in a client with mitral gurgitation?
b. Exceptional Dyspnea
d. Chest pain
B. Weight gain due to retention of fluids and worsening heart failure causes exertional dyspnea in clients with mitral
regurgitation.
17. Kris with a history of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out
whether the current problem is in renal origin, the nurse should assess whether the client has discomfort or pain in the…
83
aoih0718
Pedia
a. Urinary meatus
c. Suprapubic area
D. Discomfort or pain is a problem that originates in the kidney. It is felt at the costovertebral angle on the affected
side.
18. Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and characteristics, Nurse Perry
assesses which signs as the best indicator of renal function.
a. Blood pressure
b. Consciousness
d. Pulse rate
A. Perfusion can be best estimated by blood pressure, which is an indirect reflection of the adequacy of cardiac
output.
19. John suddenly experiences a seizure, and Nurse Gina notice that John exhibits uncontrollable jerking movements. Nurse Gina
documents that John experienced which type of seizure?
a. Tonic seizure
b. Absence seizure
c. Myoclonic seizure
d. Clonic seizure
C. Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle
group.
20. Smoking cessation is critical strategy for the client with Burgher’s disease, Nurse Jasmin anticipates that the male client will go
home with a prescription for which medication?
a. Paracetamol
b. Ibuprofen
c. Nitroglycerin
d. Nicotine (Nicotrol)
D. Nicotine (Nicotrol) is given in controlled and decreasing doses for the management of nicotine withdrawal
syndrome
21. Nurse Lilly has been assigned to a client with Raynaud’s disease. Nurse Lilly realizes that the etiology of the disease is unknown
but it is characterized by:
84
aoih0718
Pedia
D. Raynaud’s disease is characterized by vasospasms of the small cutaneous arteries that involves fingers and toes.
22. Nurse Jamie should explain to male client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing
because…
a. More accurate
c. It is easy to perform
A. Urine testing provides an indirect measure that maybe influenced by kidney function while blood glucose
testing is a more direct and accurate measure
23. Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic therapy, Jessie weighs 205.5 pounds. The
nurse could estimate the amount of fluid Jessie has lost…
a. 0.3 L
b. 1.5 L
c. 2.0 L
d. 3.5 L
C. One liter of fluid approximately weighs 2.2 pounds. A 4.5 pound weight loss equals to approximately 2L.
24. Nurse Donna is aware that the shift of body fluids associated with Intravenous administration of albumin occurs in the process
of:
a. Osmosis
b. Diffusion
c. Active transport
d. Filtration
A. Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute
concentration.
25. Myrna a 52 year old client with a fractured left tibia has a long leg cast and she is using crutches to ambulate. Nurse Joy
assesses for which sign and symptom that indicates complication associated with crutch walking?
d. Forearm weakness
D. Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the axillae.
85
aoih0718
Pedia
26. Which of the following statements should the nurse teach the neutropenic client and his family to avoid?
B. Neutropenic client is at risk for infection especially bacterial infection of the gastrointestinal and respiratory tract.
27. A female client is experiencing painful and rigid abdomen and is diagnosed with perforated peptic ulcer. A surgery has been
scheduled and a nasogastric tube is inserted. The nurse should place the client before surgery in
a. Sims position
b. Supine position
c. Semi-fowlers position
C. Semi-fowlers position will localize the spilled stomach contents in the lower part of the abdominal cavity.
28. Which nursing intervention ensures adequate ventilating exchange after surgery?
C. Positioning the client laterally with the neck extended does not obstruct the airway so that drainage of
secretions and oxygen and carbon dioxide exchange can occur.
29. George who has undergone thoracic surgery has chest tube connected to a water-seal drainage system attached to suction.
Presence of excessive bubbling is identified in water-seal chamber, the nurse should…
B. Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion.
30. A client who has been diagnosed of hypertension is being taught to restrict intake of sodium. The nurse would know that the
teachings are effective if the client states that…
31. A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulted to ascites. The nurse should be
aware that the ascites is most likely the result of increased…
A. Enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting to ascites.
32. A newly admitted client is diagnosed with Hodgkin’s disease undergoes an excisional cervical lymph node biopsy under local
anesthesia. What does the nurse assess first after the procedure?
a. Vital signs
b. Incision site
c. Airway
d. Level of consciousness
C. Assessing for an open airway is the priority. The procedure involves the neck, the anesthesia may have
affected the swallowing reflex or the inflammation may have closed in on the airway leading to ineffective air
exchange.
33. A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock?
A. Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg.
34. Nurse Lucy is planning to give pre operative teaching to a client who will be undergoing rhinoplasty. Which of the following
should be included?
D. Aspirin containing medications should not be taken 14 days before surgery to decrease the risk of bleeding.
35. Paul is admitted to the hospital due to metabolic acidosis caused by Diabetic ketoacidosis (DKA). The nurse prepares which of
the following medications as an initial treatment for this problem?
87
aoih0718
Pedia
a. Regular insulin
b. Potassium
c. Sodium bicarbonate
d. Calcium gluconate
A. Metabolic acidosis is anaerobic metabolism caused by lack of ability of the body to use circulating glucose.
Administration of insulin corrects this problem.
36. Dr. Marquez tells a client that an increase intake of foods that are rich in Vitamin E and beta-carotene are important for healthier
skin. The nurse teaches the client that excellent food sources of both of these substances are:
D. Beta-carotene and Vitamin E are antioxidants which help to inhibit oxidation. Vitamin E is found in the following
foods: wheat germ, corn, nuts, seeds, olives, spinach, asparagus and other green leafy vegetables. Food sources of
beta-carotene include dark green vegetables, carrots, mangoes and tomatoes.
37. A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client that after every meals, the client
should…
A. Gravity speeds up digestion and prevents reflux of stomach contents into the esophagus.
38. After gastroscopy, an adaptation that indicates major complication would be:
b. Abdominal distention
c. Increased GI motility
d. Difficulty in swallowing
B. Abdominal distension may be associated with pain, may indicate perforation, a complication that could lead to
peritonitis.
39. A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions that must be followed.
Nurse Hilary would recognize that the dietary teaching was well understood when the client tells a family member that:
a. “Most people need to eat a high protein diet for 12 months after surgery”
b. “I should not eat those foods that upset me before the surgery”
88
aoih0718
Pedia
d. “Most people can tolerate regular diet after this type of surgery”
D. It may take 4 to 6 months to eat anything, but most people can eat anything they want.
40. Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs and symptoms related to
Hepatitis that may develop. The one that should be reported immediately to the physician is:
a. Restlessness
b. Yellow urine
c. Nausea
41. Which of the following antituberculosis drugs can damage the 8th cranial nerve?
a. Isoniazid (INH)
d. Streptomycin
D. Streptomycin is an aminoglycoside and damage on the 8th cranial nerve (ototoxicity) is a common side effect of
aminoglycosides.
42. The client asks Nurse Annie the causes of peptic ulcer. Nurse Annie responds that recent research indicates that peptic ulcers
are the result of which of the following:
b. Stress
D. Most peptic ulcer is caused by Helicopter pylori which is a gram negative bacterium.
43. Ryan has undergone subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will be what color for about
12 to 24 hours after surgery?
a. Bile green
b. Bright red
c. Cloudy white
d. Dark brown
D. 12 to 24 hours after subtotal gastrectomy gastric drainage is normally brown, which indicates digested food.
89
aoih0718
Pedia
44. Nurse Joan is assigned to come for client who has just undergone eye surgery. Nurse Joan plans to teach the client activities
that are permitted during the post operative period. Which of the following is best recommended for the client?
a. Watching circus
b. Bending over
c. Watching TV
d. Lifting objects
C. Watching TV is permissible because the eye does not need to move rapidly with this activity, and it does not
increase intraocular pressure.
45. A client suffered from a lower leg injury and seeks treatment in the emergency room. There is a prominent deformity to the lower
aspect of the leg, and the injured leg appears shorter that the other leg. The affected leg is painful, swollen and beginning to
become ecchymotic. The nurse interprets that the client is experiencing:
a. Fracture
b. Strain
c. Sprain
d. Contusion
A. Common signs and symptoms of fracture include pain, deformity, shortening of the extremity, crepitus and
swelling.
46. Nurse Jenny is instilling an otic solution into an adult male client left ear. Nurse Jenny avoids doing which of the following as part
of the procedure
C. The dropper should not touch any object or any part of the client’s ear.
47. Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptom?
d. A temperature of 37.6 °C
A. Sudden decrease in drainage or onset of severe abdominal pain should be reported immediately to the physician
because it could mean that obstruction has been developed.
48. Jerry has diagnosed with appendicitis. He develops a fever, hypotension and tachycardia. The nurse suspects which of the
following complications?
a. Intestinal obstruction
90
aoih0718
Pedia
b. Peritonitis
c. Bowel ischemia
49. Which of the following compilations should the nurse carefully monitors a client with acute pancreatitis.
a. Myocardial Infarction
b. Cirrhosis
c. Peptic ulcer
d. Pneumonia
D. A client with acute pancreatitis is prone to complications associated with respiratory system.
50. Which of the following symptoms during the icteric phase of viral hepatitis should the nurse expect the client to inhibit?
a. Watery stool
b. Yellow sclera
c. Tarry stool
d. Shortness of breath
B. Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and
the urine dark and frothy.
Set 03
Medical- Surgical Nursing
1. A client is scheduled for insertion of an inferior vena cava (IVC) filter. Nurse Patricia consults the physician about withholding
which regularly scheduled medication on the day before the surgery?
a. Potassium Chloride
b. Warfarin Sodium
c. Furosemide
d. Docusate
. B. In preoperative period, the nurse should consult with the physician about withholding Warfarin Sodium to avoid
occurrence of hemorrhage.
2. A nurse is planning to assess the corneal reflex on unconscious client. Which of the following is the safest stimulus to touch the
client’s cornea?
a. Cotton buds
91
aoih0718
Pedia
b. Sterile glove
d. Wisp of cotton
D. A client who is unconscious is at greater risk for corneal abrasion. For this reason, the safest way to test the cornel
reflex is by touching the cornea lightly with a wisp of cotton.
3. A female client develops an infection at the catheter insertion site. The nurse in charge uses the term “iatrogenic” when describing
the infection because it resulted from:
b. Therapeutic procedure
c. Poor hygiene
B. Iatrogenic infection is caused by the heath care provider or is induced inadvertently by medical treatment or
procedures.
4. Nurse Carol is assessing a client with Parkinson’s disease. The nurse recognize bradykinesia when the client exhibits:
a. Intentional tremor
b. Paralysis of limbs
c. Muscle spasm
5. A client who suffered from automobile accident complains of seeing frequent flashes of light. The nurse should expect:
a. Myopia
b. Detached retina
c. Glaucoma
d. Scleroderma
6. Kate with severe head injury is being monitored by the nurse for increasing intracranial pressure (ICP). Which finding should be
most indicative sign of increasing intracranial pressure?
a. Intermittent tachycardia
b. Polydipsia
c. Tachypnea
d. Increased restlessness
92
aoih0718
Pedia
. D. Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.
7. A hospitalized client had a tonic-clonic seizure while walking in the hall. During the seizure the nurse priority should be:
C. Rhythmic contraction and relaxation associated with tonic-clonic seizure can cause repeated banging of head.
8. A client has undergone right pneumonectomy. When turning the client, the nurse should plan to position the client either:
b. High fowlers
A. Right side lying position or supine position permits ventilation of the remaining lung and prevent fluid from draining
into sutured bronchial stump.
9. Nurse Jenny should caution a female client who is sexually active in taking Isoniazid (INH) because the drug has which of the
following side effects?
a. Prevents ovulation
C. Isoniazid (INH) interferes in the effectiveness of oral contraceptives and clients of childbearing age should be counseled
to use an alternative form of birth control while taking this drug.
10. A client has undergone gastrectomy. Nurse Jovy is aware that the best position for the client is:
b. Low fowler’s
c. Prone
d. Supine
. B. A client who has had abdominal surgery is best placed in a low fowler’s position. This relaxes abdominal muscles and
provides maximum respiratory and cardiovascular function.
11. During the initial postoperative period of the client’s stoma. The nurse evaluates which of the following observations should be
reported immediately to the physician?
93
aoih0718
Pedia
12. Kate which has diagnosed with ulcerative colitis is following physician’s order for bed rest with bathroom privileges. What is the
rationale for this activity restriction?
a. Prevent injury
d. Conserve energy
C. The rationale for activity restriction is to help reduce the hypermotility of the colon.
13. Nurse KC should regularly assess the client’s ability to metabolize the total parenteral nutrition (TPN) solution adequately by
monitoring the client for which of the following signs:
a. Hyperglycemia
b. Hypoglycemia
c. Hypertension
A. During Total Parenteral Nutrition (TPN) administration, the client should be monitored regularly for hyperglycemia.
14. A female client has an acute pancreatitis. Which of the following signs and symptoms the nurse would expect to see?
a. Constipation
b. Hypertension
c. Ascites
d. Jaundice
D. Jaundice may be present in acute pancreatitis owing to obstruction of the biliary duct.
15. A client is suspected to develop tetany after a subtotal thyroidectomy. Which of the following symptoms might indicate tetany?
A. Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or removed.
94
aoih0718
Pedia
16. A 58 year old woman has newly diagnosed with hypothyroidism. The nurse is aware that the signs and symptoms of
hypothyroidism include:
a. Diarrhea
b. Vomiting
c. Tachycardia
d. Weight gain
D. Typical signs of hypothyroidism includes weight gain, fatigue, decreased energy, apathy, brittle nails, dry skin, cold
intolerance, constipation and numbness.
17. A client has undergone for an ileal conduit, the nurse in charge should closely monitor the client for occurrence of which of the
following complications related to pelvic surgery?
a. Ascites
b. Thrombophlebitis
c. Inguinal hernia
d. Peritonitis
B. After a pelvic surgery, there is an increased chance of thrombophlebitits owing to the pelvic manipulation that can
interfere with circulation and promote venous stasis.
18. Dr. Marquez is about to defibrillate a client in ventricular fibrillation and says in a loud voice “clear”. What should be the action of
the nurse?
d. Steps away from the bed and make sure all others have done the same
D. For the safety of all personnel, if the defibrillator paddles are being discharged, all personnel must stand back and be
clear of all the contact with the client or the client’s bed.
19. A client has been diagnosed with glomerulonephritis complains of thirst. The nurse should offer:
a. Juice
b. Ginger ale
c. Milk shake
d. Hard candy
D. Hard candy will relieve thirst and increase carbohydrates but does not supply extra fluid.
20. A client with acute renal failure is aware that the most serious complication of this condition is:
a. Constipation
b. Anemia
95
aoih0718
Pedia
c. Infection
d. Platelet dysfunction
C. Infection is responsible for one third of the traumatic or surgically induced death of clients with renal failure as well as
medical induced acute renal failure (ARF).
21. Nurse Karen is caring for clients in the OR. The nurse is aware that the last physiologic function that the client loss during the
induction of anesthesia is:
a. Consciousness
b. Gag reflex
c. Respiratory movement
d. Corneal reflex
C. There is no respiratory movement in stage 4 of anesthesia, prior to this stage, respiration is depressed but present.
22. The nurse is assessing a client with pleural effusion. The nurse expect to find:
B. Compression of the lung by fluid that accumulates at the base of the lungs reduces expansion and air exchange.
23. A client admitted with newly diagnosed with Hodgkin’s disease. Which of the following would the nurse expect the client to
report?
b. Weight gain
c. Night sweats
d. Headache
. C. Assessment of a client with Hodgkin’s disease most often reveals enlarged, painless lymph node, fever, malaise and
night sweats.
24. A client has suffered from fall and sustained a leg injury. Which appropriate question would the nurse ask the client to help
determine if the injury caused fracture?
25. The Nurse is assessing the client’s casted extremity for signs of infection. Which of the following findings is indicative of
infection?
a. Edema
D. Signs and symptoms of infection under a casted area include odor or purulent drainage and the presence of “hot spot”
which are areas on the cast that are warmer than the others.
26. Nurse Rhia is performing an otoscopic examination on a female client with a suspected diagnosis of mastoiditis. Nurse Rhia
would expect to note which of the following if this disorder is present?
B. Otoscopic examnation in a client with mastoiditis reveals a dull, red, thick and immobile tymphanic membrane with or
without perforation.
27. Nurse Jocelyn is caring for a client with nasogastric tube that is attached to low suction. Nurse Jocelyn assesses the client for
symptoms of which acid-base disorder?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
d. Metabolic alkalosis
D. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric
acid which is a potent acid in the body.
28. A male adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. Which of the following
values should be negative if the CSF is normal?
c. Insulin
d. Protein
. A. The adult with normal cerebrospinal fluid has no red blood cells.
29. A client is suspected of developing diabetes insipidus. Which of the following is the most effective assessment?
97
aoih0718
Pedia
D. Measuring the urine output to detect excess amount and checking the specific gravity of urine samples to determine
urine concentration are appropriate measures to determine the onset of diabetes insipidus.
30. A 58 year old client is suffering from acute phase of rheumatoid arthritis. Which of the following would the nurse in charge
identify as the lowest priority of the plan of care?
c. Relieving pain
B. The nurse should focus more on developing less stressful ways of accomplishing routine task.
a. Edema
b. Swelling
c. Redness
d. Coolness
33. Nurse Becky is caring for client who begins to experience seizure while in bed. Which action should the nurse implement to
prevent aspiration?
A. Positioning the client on one side with head flexed forward allows the tongue to fall forward and facilitates drainage
secretions therefore prevents aspiration.
98
aoih0718
Pedia
34. A client has undergone bone biopsy. Which nursing action should the nurse provide after the procedure?
C. Nursing care after bone biopsy includes close monitoring of the punctured site for bleeding, swelling and hematoma
formation.
35. A client is suffering from low back pain. Which of the following exercises will strengthen the lower back muscle of the client?
a. Tennis
b. Basketball
c. Diving
d. Swimming
D. Walking and swimming are very helpful in strengthening back muscles for the client suffering from lower back pain.
36. A client with peptic ulcer is being assessed by the nurse for gastrointestinal perforation. The nurse should monitor for:
C. Sudden, severe abdominal pain is the most indicative sign of perforation. When perforation of an ulcer occurs, the
nurse maybe unable to hear bowel sounds at all.
37. A client has undergone surgery for retinal detachment. Which of the following goal should be prioritized?
b. Alleviate pain
A. After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal.
38. A Client with glaucoma has been prescribed with miotics. The nurse is aware that miotics is for:
a. Constricting pupil
99
aoih0718
Pedia
A. Miotic agent constricts the pupil and contracts ciliary muscle. These effects widen the filtration angle and permit
increased out flow of aqueous humor.
39. When suctioning an unconscious client, which nursing intervention should the nurse prioritize in maintaining cerebral perfusion?
a. Administer diuretics
b. Administer analgesics
c. Provide hygiene
D. It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and to maintain cerebral
perfusion.
40. When discussing breathing exercises with a postoperative client, Nurse Hazel should include which of the following teaching?
41. Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s comfort, the nurse should:
C. A Client with burns is very sensitive to temperature changes because heat is loss in the burn areas.
42. Nurse Trish is aware that temporary heterograft (pig skin) is used to treat burns because this graft will:
A. The graft covers the nerve endings, which reduces pain and provides framework for granulation.
43. Mark has multiple abrasions and a laceration to the trunk and all four extremities says, “I can’t eat all this food”. The food that the
nurse should suggest to be eaten first should be:
100
aoih0718
Pedia
B. Meat provides proteins and the fruit proteins vitamin C that both promote wound healing.
44. Tony returns form surgery with permanent colostomy. During the first 24 hours the colostomy does not drain. The nurse should
be aware that:
C. This is primarily caused by the trauma of intestinal manipulation and the depressive effects anesthetics and analgesics.
45. When teaching a client about the signs of colorectal cancer, Nurse Trish stresses that the most common complaint of persons
with colorectal cancer is:
a. Abdominal pain
b. Hemorrhoids
D. Constipation, diarrhea, and/or constipation alternating with diarrhea are the most common symptoms of colorectal
cancer.
46. Louis develops peritonitis and sepsis after surgical repair of ruptures diverticulum. The nurse in charge should expect an
assessment of the client to reveal:
a. Tachycardia
b. Abdominal rigidity
c. Bradycardia
B. With increased intraabdominal pressure, the abdominal wall will become tender and rigid.
47. Immediately after liver biopsy, the client is placed on the right side, the nurse is aware that that this position should be
maintained because it will:
101
aoih0718
Pedia
A. Pressure applied in the puncture site indicates that a biliary vessel was puncture which is a common complication after
liver biopsy.
48. Tony has diagnosed with hepatitis A. The information from the health history that is most likely linked to hepatitis A is:
B. Hepatitis A is primarily spread via fecal-oral route. Sewage polluted water may harbor the virus.
49. Nurse Trish is aware that the laboratory test result that most likely would indicate acute pancreatitis is an elevated:
c. Potassium level
d. Sodium level
B. Amylase concentration is high in the pancreas and is elevated in the serum when the pancreas becomes acutely
inflamed and also it distinguishes pancreatitis from other acute abdominal problems.
50. Dr. Marquez orders serum electrolytes. To determine the effect of persistent vomiting, Nurse Trish should be most concerned
with monitoring the:
A. Sodium, which is concerned with the regulation of extracellular fluid volume, it is lost with vomiting. Chloride, which
balances cations in the extracellular compartments, is also lost with vomiting, because sodium and chloride are
parallel electrolytes, hyponatremia will accompany.
102
aoih0718