PEDIATRIC NURSING FINAL EXAM STUDY GUIDE

ENDOCRINE [5 Questions]

 Type 1 Diabetes Mellitus

o “Insulin deficient”
o Insulin levels will be LOW
o Destruction of beta cells in the pancreas
o Idiopathic
o Clinical Manifestations:
 3 P’s
 Polydipsia
 Polyuria
 Polyphagia
 Weight loss
 Elevated glucose (200 mg/dL or more)
 Ketones
o Diagnostic Criteria
 Fasting glucose >126
 Random glucose >200 & symptomatic
 Hgb A1C >6.5%
 Normal is 4-6%
 To prevent long term complications want it below 7%
o Treatment
 Insulin replacement
 Rapid Acting (Humalog, Novolog, Apidra, Lispro)
o Onset: 0-15 min
o Peak: 30-90 min
o Duration: 3-5 hours
o Take with/right before meals!
 Short Acting (Regular and Velosolin)
o Onset: 30 min
o Peak: 2-4 hours
o Duration: 4-8 hours
 Intermediate Acting (NPH and Lente)
o Onset: 2-6 hours
o Peak: 4-14 hours
o Duration: 14-20 hours
 Long Acting/basal (Lantus, Ultralente and Levemir)
o No peak
o Duration: 20-24 hours
 Set dose regimen
  Used for a kid who is expected to eat a set number of
carbs at each meal and snack
 NPH and Regular insulin is used
 Before breakfast and dinner
 Timing is crucial and strict schedule for meals and
injections
 Insulin Injections:
 Always rotate sites
 Count to five before removing needle from skin
 No set age when child can give his/her own shots
o Insulin Pumps:
 Delivers a fixed amount of regular or lispro continuously
 Closely imitates the release of the hormone by the islet cells
 Pump must be programmed to deliver a dose before each meal
 This should be used on a child who is able to calculate carbs and
manage/make changes to their pump
o Monitoring effectiveness of insulin therapy
 Serum glucose
 Excellent method of insulin adjustment
 Should be maintained between 80-120 mg/dL
o Urine ketone testing
 Especially during illness or whenever blood glucose is 240 or
greater
o Monitoring Blood Sugars
 Always check glucose before everything
 Meals, bedtime, not feeling well, not acting normal
o Nutrition
 Nutritional needs are the same as healthy children
 Balanced carbs, fats and proteins
 Timing of food consumption must e regulated to correspond to
the time and action of the insulin
 Consistent caloric intake on a day to day basis
 Extra food during periods of exercise to prevent hypoglycemia
 Avoid high sugar/carb foods to prevent hyperglycemia
 Average carb intake should be 30 grams for snacks and 50 grams
for meals
o Exercise
 Children with diabetes should participate fully in physical
education and sports
 Need to monitor blood glucose before, during and after
exercise
 May need to have a carb snack before participating
 Or lower insulin dose taken beforehand
 o Adolescents have the most difficult time adjusting to DM
 Developmentally they want to be like their peers but they feel
different
 Denial by omitting insulin, not eating right or monitoring sugars
 Eating disorders
 Puberty can cause difficulty maintaining glucose control due to
decreased insulin sensitivity and may need a drastic increase of
insulin dose
o Education
 Reinforcement the information for the family and child
 Insulin admin, glucose monitoring, observing for complications
 Hypoglycemia
o Blood sugar less than 70 mg/dL
o Due to:
 Too little food
 Too much insulin
 Increased exercise
 Skipping/delaying meals
o Symptoms
 Shaky
 Sweaty
 Hungry
 Disoriented
 Headache/blurry vision
 Sleepy
 Dizziness/confusion
 Lethargic/weakness
 Pale
o Treatment
 15 grams of quick acting carb before
 Orange juice
 Honey
 Lifesavers
 Butterscotch
 For unconscious/seizures with hypoglycemia
 Place in recovery position
 Give glucagon IM
 Should wake up in ~15 minutes
 Feed once they are awake
 Hyperglycemia
o High blood sugar due to:
 Too little insulin
 Too much food
  Illness
 Infection
 Injury
 Stress
 Emotional upset
o Signs/symptoms
 Polydipsia
 Polyuria
 Nausea
 Blurry vision
 Fatigue
 Decreased cognitive abilities
 Irritability
o Treatment
 Insulin
 Fluidsto prevent dehydration
 Exercise (hold if ketones are present)
o Long-term complications
 Retinopathy
 Nephropathy
 Peripheral neuropathy
 Problems with GU, GI, cardiovascular, & sexual dysfunction
 Increased incident of atherosclerotic cardiovascular, peripheral,
arterial & cerebrovascular diseases (HTN & abnormal lipids)

*Goal is to keep glucose in normal ranges to avoid/delay these complications

 DKA
o Life threatening complication due to an excessive amount of ketone
production and lack of insulin
o Symptoms
 Lethargy
 N/V
 Abdominal pain
o Treatment
 Fluids
 Insulin
 1 ounce/year/hour
o Care for a child with DM
 Acute
 May need to be hospitalized during illness or episodes of
DKA
 Hospital
  Requires intensive nursing care (frequent vitals, weight,
I&Os, IV fluids and electrolytes, insulin, blood glicose
levels, LOC)
 Diabetic flowsheet provides an ongoing record of all the
above
 Type 2 DM
o Insulin resistance/failure of insulin to act on tissues and insulin deficiency
o “Non insulin dependent”
 Has the ability to produce insulin but does not use it
correctlyoverproduction of insulin
 This can result in beta cell exhaustioninsulin deficiency
o Insulin levels will be HIGH
o Due to obesity and decreased exercise/sedentary lifestyle
o Risk Factors:
 Obesity*** (BMI >85%)
 Family history
 Maternal gestational diabetes
 Physical inactivity
 Race (AA, Hispanics, Asians, Native Americans)
 More common in girls
o Clinical Manifestations
 Ketonuria
 Recurrent infections (vaginal candida, UTIs)
 Subtle increase in thirst or urination
 Acanthosis nigricans
 Velvety thickening and darkening of skin found on back of
neck, axillae, thighs or skin folds
 Sign of insulin resistance
 Gradual onset
o Diagnostic Criteria
 Fasting glucose >126
 Random glucose >200
 Oral glucose tolerance test >200
 Elevated cholesterol, triglycerides and insulin
o Treatment
 Diet- main goal is to lose weight because it will lower their
glucose and cholesterol!
 Exercise
 Weight management
 Lifestyle changes
 Medications
 Metformin
 Increases insulin sensitivity
  Suppresses appetite
 Improves lipid profile
 Reduces hepatic glucose output
 Patients with glucose >200 will require insulin
 Once glucose is under control they can switch to
oral agents
o Complications
 Damage to the kidney, retina, vascular and nervous systems
o Organ damage is proportional to the degree of hyperglycemia as
well as the duration of exposure

RESPIRATORY [7 Questions]
 The space between the upper and lower respiratory tract are so close that
infections can easily spread from one to another
o These infections can become otitis media because of the small and open
Eustachian tubes
 Viruses cause the most infections
o Respiratory Syncytial Virus (RSV), coxsackieviruses, parainfluenza
o Haemophilus Influenza and Pneumococci can be prevented by
vaccinations
 Infants <3 months: lower infection rates due to maternal antibodies
 3-6 months: infection rates increase because maternal antibodies wear off
 Toddler/Preschool: viral infection rate remains high b/c of daycare/school
 5 years or older: viral infection rates decrease, bacterial infections increase
 Resistance
o Ability of the body to resist pathogens
o Resistance can be decreased due to
 Malnutrition
 Anemia
 Fatigue
 Allergies
 Preterm birth
 Asthma
 Daycare attendance
 Secondhand smoke exposure
 Seasonal Infections:
o Winter/Spring: RSV and Influenza A and B
o Autumn/Early Winter: Mycoplasmal infections
o Winter/Cold Weather: asthmatic Bronchitis
 Assessment:
o Rate, effort
o Evidence of infection (enlarged nodes, fever)
o Cough
 o Wheeze
o Cyanosis
o Chest pain
o Nasal mucus
o Halitosis from breathing with their mouth open
o Change in respiratory status
 Nasopharyngitis
o Common cold
o Caused by RSV
o Clinical Manifestations
 Fever
 Nasal congestion
 Irritable
 Poor feeding
 Sneezing/coughing
 Muscle aches
o Treatment
 No specific treatment
 Antipyretics, rest and increase fluids
 No decongestants for kids under 4
 Pharyngitis (Strep)
o Majority is viral
 Some caused by bacteria streptococci
o Abrupt onset
o Clinical manifestations
 Fever
 Sore throat
 Headache
 Anterior cervical adenopathy
 Tonsils & pharynx may be inflamed & covered in exudate
o Diagnostic tests
 Rapid strep test
 Hit the pharynx with swab
 Two lines= positive GABHS (strep)
 Negative= likely viral
o Treatment
 Penicillin
 If allergic to this then give erythromycin or cephalosporin’s
 Can get rheumatic fever or acute glomerulonephritis is not
properly treated
o Nursing Management
 Pain: gargle with warm water
 Complete entire 10 days of antibiotic
  New toothbrush to prevent new infection
 Not contagious after 24 hours on antibiotic
 Tonsillitis
o Tonsils and adenoids protect the body from infection
o Can get acute and chronic infections
o Often occurs with pharyngitis
 If it tests positive for strep, treat it as strep
o Clinical manifestations
 Fever
 Sore throat
 Headache
 Anterior cervical adenopathy
 Tonsils & pharynx may be inflamed & covered in exudate
 Snoring at night
o Treatment
 Warm water gargles
 Mild analgesics (acetaminophen)
o Post-Surgical Interventions
 Ice collar for inflammation
 Monitor for bleeding
 Risk for bleeding occurs 7-10 days after surgery because
this is when the scab falls off
 Signs:
 Drooling bright red blood
 Frequent swallowing (trying to clear airway of
blood)
 N/V from anesthesia
 Important because they can rip their stitches
 Give anti-emetics
 Fluids
 Pain management
 Diet:
 Soft foods, soups, mashed potatoes
 Avoid milk and ice cream b/c it coats the mouth and the
child will cough to clear their throat and it can rip the
stitches
 Avoid rough, scratchy, spicy foods
 Otitis Media
o Most frequent diagnosis
 Most prevalent in infancy (6-24 months)
o Presence of fluid in the middle ear with inflammation
o Risk factors:
 6-18 months b/c of the anatomy of Eustachian tubes
  Daycare
 Formula fed infants
 Secondhand smoke
 Pacifier use
 Fall/Winter seasons
 Underlying disease (cleft palate, down syndrome, allergic rhinitis)
o Clinical Manifestations
 URI, nasal congestion, allergies (antecedent event)
 High fever
 Otalgia-ear pain
 Hearing loss
 Otorrhea
o Treatment
 Oral antibiotics- high dose Amoxicillin for 10 days
 If no improvement in 2-3 days may need different antibiotic
o Nursing Management
 No pacifier use
 Elevate when bottle feeding
 No secondary smoke exposure
 Ibuprofen or acetaminophen for pain

CROUP SYNDROMES
 Acute epiglottis
o Inflammation of the epiglottis and supraglottis
o Blocks the airway
o Without treatment can progress to life-threatening airway obstruction
o Hib is the most common infectious cause
o Most common in kids 2-8 years old
o Clinical Manifestations
 Abrupt onset
 Sore throat
 Pain on swallowing
 3 D’s (dysphagia, drooling, distress)
 Fever
 Tripod position
 Drooling
 Irritable
 Retractions may be evident
o Nursing Management
 Do NOT examine the throat
 No tongue depressors or saying “ah”
 Put on oxygen (humidified)
  X-ray immediately
 Thumb sign straight to surgery and intubated
 Maintaining airway is the main focus!
o Treatment
 Nebulized epinephrine
 Corticosteroids
 Can be prevented with Hib vaccines
 Acute laryngotracheobronchitis
o Most common croup syndrome
o Commonly affects kids <5 years old
o Usually preceded by a URI
o Starts as a cold then gradually descends to structures
o Clinical Manifestations
 Gradual onset of low-grade fever
 Barky cough (seal)
 Inspiratory stridor
 Hoarseness
 Can progress to respiratory failure
o Treatment
 Maintaining airway is primary goal
 High humidity with cool mist
 Antipyretics
 Dexamethasone to reduce swelling
 Nebulized epinephrine
 Bronchitis
o Inflammation of trachea and bronchi
o Associated with URI
o Viral <6 years old, bacterial pneumonia >6 years old
o Dry hacking, nonproductive cough
o Self-limiting (5-10 days)
o Rest, antipyretics, humidity
 Bronchiolitis (RSV)
o Acute viral infection
o Winter and early spring seasons
o Most frequent cause of hospitalization in kids under 1 year
 Because of dehydration
o Clinical Manifestations
 Begins with URI
 Low grade fever
 Otitis media
 Conjunctivitis
 Cough, wheezing, poor feeding
o Diagnostic tests
  Nasal secretions
 Rapid immunoflorescent antibody (DFA)
o Treatment
 Cool humidified oxygen
 Fluid hydration
 Bronchodilators
 Saline nebulizers
o Prevention:
 Avoid smoke exposure
 Avoid daycare during RSV season
 Hand washing
 Maintain patent airway
 Suction nares
 Adequate fluid intake
 Pneumonias
o Inflammation of the pulmonary parenchyma
o Occurs frequently in infancy and early childhood
o Viral or bacterial
 Bacterial pneumonia
 Infants <4 months: requires hospitalization
 4 months-4 years: strep is the most common cause
 Cough and fever are the most common symptoms
 Tachypnea, malaise, crackles, decreased breath
sounds or rales
 Treat with amoxicillin
 5 years or older:
 Atypical: mycoplasma pneumoniae and
chlamydophilia are the most common pathogens
 Fall and winter months
 Treated with erythromycin, clarithromycin or
azithromycin (Z pack)
o Nursing Management
 Adequate oxygenation
 Monitor respiratory status
 Color, work of breathing, lung sounds
 Compare your last assessment with the current one
 If there is a change for the worseRESPOND
 Frequent monitoring every 2 hours
 Adequate hydration
 Asthma
o Chronic inflammatory disease of the airways
o Hyperreactivity
 Airway smooth muscle contracts in response to triggers
 o Obstruction
 Swelling/inflammation
 Hypersecretion of mucus and mucus plugging
o Clinical Manifestations
 Wheezing- musical/high pitched sound
 Prolonged expiratory phase
 Coughing night cough= hallmark sign, nonproductive and dry
 Chest tightness
 Shortness of breath
 Retractions
o Diminished breath sounds during asthma exacerbation= medical
emergency
o Diagnostic tests
 History of recurrent wheezing, coughing with difficulty breathing
 PFT
 FEV1 is reduced in asthma
 Exercise Induced Bronchospasm (EIB)
o Exercise is the only precipitant of asthma symptoms
o Occurs minutes after vigorous activity and peaks at 5-10 minutes
o Diagnostic tests
 Exercise challenge test
o Treatment
 Inhaled beta 2 agonists shortly before exercising
 Short acting B-2 agonist (SABA)
 For acute relief of symptoms, rapid onset and short
duration
 Relaxes smooth muscle in the airway
 Albuterol/Xopenex
 MDI or nebulizer
 MDI needs spacer
 Long acting B-2 agonist (LABA)
 Slower onset, long duration (12 hours)
 For long term control
 Salmeterol/Formoterol
 Inhaled corticosteroid
 Anti-inflammatory
 Budesonide/fluticasone
 Combination of SABA, LABA and ICS is the best treatment to get
them to breathe better
o Prevention:
 Know triggers, avoid common respiratory irritants
o Peak Flow Meter
 Make sure device is at 0
  Stand up
 Take a deep breath
 Place meter in mouth
 Blow out as hard and fast as possible
 Repeat twice and take best reading
 Green 80-100% of personal best
 Continue as usual
 Yellow 50-80% of personal best
 Give rescue meds
 Red below 50% of personal best
 Give rescue meds ad go to the ER
o Nursing Management
 Administer oxygen, medication and IV hydration
 Frequent monitoring
 Change in statusrespond!
o EDUCATION**
 MDI
 Prime inhaler before first use
 Shake inhaler for 5 seconds before each puff
 Use spacer
 Rinse mouth out with water
 Spacers
 Wait 15-30 seconds between puffs
 Breath in deep and slow
 Dry powder inhalers
 Breath out away from mouthpiece
o Breath quickly and deeply
o Wash mouth out
 Cystic Fibrosis
o Autosomal recessive
o Affects all exocrine glands and organs
o Progressive lung disease due to infection, inflammation and mucus
plugging
 Airtrapping, bronchiectasis and atelectasis
o Pancrease involvement
 Deficient enzymesmalabsorption, oily stools and cramping
 Vitamin A,D,E, & K deficiencies
o Liver
 Gallstones and cirrhosis
o Intestinal
 Meconium ileus at birth and obstructions
o Skin
 Salt in sweat
  Hyponatremic, hypochloremic, metabolic alkalosis
o Reproductive
 Sterile males
 Thick vaginal mucus blocks sperm from implanting in females
o Clinical Manifestations
 FTT
 Salty tasting skin
 Frequent pulmonary infections
 Digital clubbing
 Greasy stools
o Diagnostic tests
 Newborn screening
 Elevated sweat chloride test (>60)
o Treatment
 Chest physiotherapy
 Antibiotics
 Mucolytics
 Asthma treatment (if they have asthma)
 Creon (pancreatic supplement)- allows fat to be absorbed
 Increased caloric intake and vitamins
o Nursing Management
 Oxygen, nebulizers CPT
 Medications and supplements
 Nighttime enteral feedings

CARDIAC [6 Questions]

 Congenital Heart Disease

o Anatomic abnormalities present at birth resulting in abnormal cardiac
function
o Multifactorial
 Maternal factors can be in play: infections, Dilantin use,
drug/alcohol use, cardiomyopathy, lupus
 Acquired Heart Disease
o Disease process/abnormalities occur after birth
 Assessment
o Infant:
 Poor feeding
 Tires easily
 Sweating while feeding
 Sustained tachypnea
o Toddler/School-aged/Adolescents
 Activity level-fatigue
  Unable to keep up with peers
o Look at growth chart
 If they had a normal or below average curve and now suddenly
they are decliningfailure to thrive
o Palpation & percussion-thrill, weak pulses
o Auscultationtachycardia, murmurs, arrhythmias
o Clubbing
 Diagnostic tests
o Chest X-ray
o EKG
o Echo
o Cardiac catheterization
o Exercise stress test
o MRI
 Acynotic
o Increased pulmonary blood flow
o Obstruction to blood flow from ventricles
o Defects:
 ASD
 Hole in atrial septum
 Blood shunts left atrium to right atrium
 Symptoms:
 Asymptomatic
 Symptoms of CHF
 Treat with cardiac cath or open heart surgery
 VSD
 Hole in ventricular septum
 Blood shunts left ventricle to right ventricle
 Symptoms:
 Asymptomatic
 Signs of CHF
 Characteristic holosystolic murmur- starts at S1
ends in S2
 Atrioventricular canal defect
 Patent ductus arteriosus
 Cyanotic
o Decreased pulmonary blood flow
o Mixed blood flow
o Defects:
 Tetralogy of Fallot (TOF)
 Typically 4 defects:
 VSD
 Pulmonary stenosis
  Overriding aorta
 RV hypertrophy
 Clinical presentation:
 Pink Tet- not cyanotic
 Cyanotic Tet
 Treatment
 Open heart surgery
 Palliative shunt to increase pulmonary
blood flow
 Complete repair
 Tricuspid atresia
 Congestive Heart Failure
o Heart muscle becomes damaged and cannot adequately maintain cardiac
output
o Symptoms
 Tachypnea
 Tachycardia
 Weight gain
 Fluid retention
 Weak pulses
 Decreased BP
o Treatment
 Digoxin- increases cardiac output
 Before administering, take apical HR for 1 full minute
 If HR is less than 90 in infants or less than 70 in
childrenHOLD
 Watch for sinus bradycardia
 Give one hour before meals or two hours after meal
 Absorbs better on an empty stomach
 Lasix
 Gets rid of excess retained fluid to decrease BP
 Can cause orthostatic hypotension
 Administer with food or milk to avoid GI distress
 Monitor fluid and electrolytes
 Kawasaki Disease
o Mucocutaneous lymph node syndrome
o Unknown etiology
o Acute, generalized systemic vasculitis involving coronary arteries
o Self-limited
 Without treatment, can lead to coronary artery aneurysmscan
be fatal
o Diagnosis tests
  High fever >102 persisting for at least 5 days and the presence of
one of the following:
 Changes in extremities (peeling fingers and toes)
 Nonspecific polymorphous rash
 Conjunctivitis
 Changes in lips/oral cavity (strawberry tongue)
 Cervical lymphadenopathy
o Treatment
 Aspirin
 High dose during acute phase, then low dose for 6-8 weeks
 Acute Rheumatic Fever
o Usually due to an untreated strep infection
 Occurs 2-6 weeks following strep
 Exaggerated immune response to bacteria
 Usually self limiting
 Can affect the heart, joints, skin and brain
 Complication:
 Rheumatic heart disease
 Permanent damage to the heart valves as a result
of ARF (typically mitral valve followed by aortic
valve)
o Treatment
 Treat like strep
 Penicillin (or cephalosporin if allergic to penicillin’s) 2x a
day for 10 days
 Person may be on prophylactic antibiotic against future strep
infections
 Should continue until 21 years old or 10 years from most recent
acute attack
o Nursing Management
 Monitor vitals
 Monitor growth and nutrition
 Provide emotional support to patient and family
 Educate family about disease
o Pre-Op
 Maintain normalcy
 Medication teaching
 Discipline issues
o Post-Op
 Monitor Vitals
 Cardiac assessment
 Monitor output of chest tubes
 Minimize risk for infection strict hand washing
 o Discharge teaching
 Medication teaching!!!
 Patient education handouts
 Return demonstrations
 Make a medication schedule
 Activity restriction
 Wound care
 Follow-up with cardiologist
 SBE (sub-acute bacterial endocarditis) prophylaxis prior to dental
work or surgery

MUSCULOSKELETAL [5 Questions]

 Hip dysplasia
o Head of femur not fully connected to acetabular bone in joint
o Subluxation: the femoral head is partially outside the acetabulum (most
common)
o Dislocation: the femoral head is completely outside the acetabulum
o Many of these are babies who were breeched
o More common in females
o More common in Caucasians
o Risk factors
 Intrauterine positioning related to maternal hormonal secretion
 Breeched
 Multiple fetus
 Oligohydramniosdeficiency of amniotic fluid
 Large infant size
 Genetics
o Clinical manifestations
 Positive Ortolanilimited abduction (< 45 degrees)
 Positive Barlowlimited adduction
 Clunk or jerk, not a click
 Galeazzi signasymmetry of thigh folds/gluteal folds along with
shortening of the thigh
 Allis signshortening of femur, unequal level of the knees in
flexion
o Treatment (newborn to 6 months)
 Hip joint maintained in safe position with the proximal femur
centered in the acetabulum
 Palvik harness
 Continuously worn 3-5 months
 Abduction splint
 Prevents hip extension & adduction
  Check straps for adjustments
 Skin care important, avoid lotions, check 3-4 times/day,
prevent straps from rubbing against skin
 Worn 24 hours/daynot removed for bathing
 If harness ineffective a hip spice cast is applied
o Treatment (6-18 months with dislocation)
 Success rate of Palvik harness < 50%
 Closed reduction
 Femoral head is reduced into the acetabulum under
anesthesia, spica cast applied to maintain position
 Open reduction
 Femoral head reduced into the acetabulum with an
incision so that the hip capsule is opened to removed the
obstacles to reduction, spica cast applied after to maintain
position
 Spica cast
 Applied for 3-4 months
 Cast changes every 6 weeks
o Complications
 Pavlik harnessosteonecrosis
 Leg length differences
 Back complications
 Waddling gait
 Trendelenberg sign
 Legs uneven
 Need corrective surgery
o Nursing management
 Early detection
 Teach parents about correct use of harness, no adjustments
without medical supervision
 Encourage parents to hold infants & provide nurturing activities
 Importance of frequent follow-ups
 Orthopedist every 2 weeks
 With spica cast…evaluate for pain, paralysis, swelling, sensation, &
movement
 Sprains
o Joint is twisted or wrenched…from a sudden movement
o “Snap” or “Pop”
o Rapid onset of swelling & reluctance to use the injured joint
 Strains
o Microscopic tear
o Overuse injury
o Area becomes painful to touch & swollen
 o Not as common as sprains in pediatrics
o Treatment for both
 Rest
 Ice
 Compression
 Elevation
 Fractures
o Soda, fruit drinks, make bones more brittle
o Rapid decrease in calcium & phosphorus = increased incidences for
fractures
o Greenstick fracture
 Incomplete fracture
 Most common
o Oblique fracture
 Diagonal break
o Spiral fracture
 Spirals around the bone
 Twisting injury
o Transverse fracture
 Straight line break across the bone
o Physeal fracture
 Physis= top layer of the bone
 Growth arrest can occur
o Clinical manifestations
 Generalized swelling
 Pain or tenderness
 Deformity
 Diminished functional use of affected limb or digit
 Severe/limited ROM
 Obvious painuncontrollable crying or resistance to having the
area touched/examined
o Treatment
 Assess 5 P’s (Pain, pallor, pulse, parathesia, & paralysis)look at
this before & after cast is put on
 Determine mechanism of injury
 Move area of injury as little as possible
 Immobilize limb
 Elevate limb
 Apply cold to affected area
o Cast care
 Keep limb elevated after cast is put on
 Observe for complications such as decreased pulses, decreased
capillary refill, & temperaturecould mean decreased circulation
  Do not put anything down cast even if itchy (ie: blow air from
blow dryer)
o Compartment Syndrome
 When circulation is cut off
 Increased pressure within a closed space
 Leads to impaired blood flow & muscle nerve damage
 Scoliosis
o Complex spinal deformity involving lateral curve, spinal rotation, &
thoracic kyphosis
o Types
 Infantile
 Onset birth-3 years old
 Juvenile
 Onset during childhood
 Adolescent
 During a growth spurt
 Most common
o Clinical manifestations
 Clothes don’t fit right
 Back pain
 Asymmetrical shoulders & waist line
 Walks with a limp
 < 20 degree curve = observation
 > 20 degree curve = concerned
 > 50 degree curve = brace & possible surgery
 > 80 degree curve = compromises other organs
o Nursing management
 Monitor neurological function in extremities 48 hours after
surgery
 Pain management
 Immobilizationto maintain spinal alignment

DERMATOLOGY [6 Questions]

BACTERIAL INFECTIONS:
 Impetigo
o Most common in ages 2-5
o Very common
o Papules progress to vesicles surrounded by erythema
o Breakdown to form thick crust = golden appearance
o Usually around nose & mouth
o Comes from a staph infection
o Treatment
  Topical: Mupirocin
 Oral: Cephalosporins
 Hand washing!
 Folliculitis
o Infection of the hair follicles
o No antibiotics needed
o Problems comes from shaving (especially coarse hair or pubic area)
 Furuncles
o Infection of the hair follicles
o Bacteria has gone deeper into the skin, may need antibiotics
o Small abscess are formed
o Concerned with MRSA
 Carbuncles
o Infection of multiple hair follicles
o Several inflamed follicles that become one inflamed mass
o Cyst or vesicle
o Concerned with MRSA
o Treatment (for ALL 3)
 Warm compress = to promote drainage
 Incision & drainage = obtain culture to rule out MRSA
 NEVER SQEEZE LESION = some comes out, but some goes further
into the skin & makes it harder to treat
 Evidence of antibiotics not clear, usually incision & drainage are
curative
 Cellulitis
o Inflammation of skin and subcutaneous tissue
o More severe b/c greater area of skin is infected
o Skin: erythema, edema, warmth, inflammation of regional lymph nodes,
“streaking”, and fever
o Common in hospitalized immobilized kids
o Treatment
 Elevation of affected area
 Rest & immobilization of affected area
 Oral antibiotics
 IV antibiotics (if near a joint, eyes, or face)
o Nursing management
 Hand washing
 Clothing directly touching affected area should be cleaned in hot
water & changed daily
 Discard razors
 Caution child from touching affected area = to prevent spread

VIRAL INFECTIONS
  Warts
o Caused by HPV & verruca plantaris (plantar warts)
o Well-circumscribed, gray or brown, elevated, firm papules
o Rough texture
o Common on extremities (fingers, hands, & face)
o Can be single OR multiple
o Plantar wartsroots much strongerharder to get rid of
o Treatment
 Destructive therapy (surgical removal)
 Cryotherapy with liquid nitrogen
 Laser
 Lactic retinoic & salicylic acid solutions
 Herpes Simplex
o Type 1: cold sores, fever, blisters
o Type 2: genitalcan get type 1 symptoms in genital)
o Clustered, grouped, burning, itching vesicles
o Vesicles dry & form a crust
o Spontaneous healing in 8 to 10 days
o Nose, lip, genitals, & buttocks
o Will present if the body is stressed
o May not manifest itself immediately after contact
 Need to wait 3 months to look at viral load
o Treatment
 Topical therapy with Peniclovir = shorten duration of cold sores
 Oral antiviral: Acyclovir
 Valacyclovir (Valtrex) = for recurrent genital herpes
 Takes longer to diagnose because it looks like other things
 Type 2culture needed

FUNGAL SKIN INFECTIONS

 Love warm, moist areas
 Tinea capitis (ringworm of the scalp)
o Scaly, circumscribed patches with areas of alopecia
o May be pruritic
o Highly common in ages 2 to 10
o More common in boys
o Spreads from child-to-childshared hats, combs, brushes, etc.
o Can also be transmitted via pets
o Can last months to years
o More common in those with coarse hair
o Treatment
 Griseofluxin (oral antifungal) for 6-12 weeks
  If kerion presentboggy inflammation (cushion in their scalp)
due to an allergic reaction
 Give 7-10 day course of prednisone to decrease
inflammation
 Tinea corporis (ringworm of the body)
o Round/oval erythematous scaling patch with clear centrally
o Multiple lesions (may be pruritic)
o Usually from infected pets
o Usually seen on non-hairy body parts (face, trunk, under arms)
o May be hyper-pigmented in darker-skinned individuals
o Treatment
 Daily application of topical antifungalsapplied 3x/day for 2
weeks & 1-2 weeks after no signs of lesions
 May need oral griseofulvin if topical is ineffective
 Should be given with foods high in fat for best absorption
 Put antifungals on at night so the child won’t rub it off
 Tinea pedis (ringworm of the feet)
o “Athlete’s foot”
o Intensely pruritic erythematous vesicles or bullae between the toes & on
the soles of feet
o Often follow activities that cause feet to sweat
o Can be intermittent, recurrent, or chronic
o If untreated…can cause scaling & spread to the nails
o Treatment
 Topical antifungal cream for 4 weeks
 Chronic may require oral antifungal therapy (up to 8 weeks)
 Keep areas clean & dry (FOR ALL OF THESE)
 Atopic Dermatitis
o Also known as eczema
o Not contagious
o Genetic defect in the proteins supporting the epidermal barrier
o May have elevated IgE levels associated with asthma & higher sensitivity
to allergens
o Clinical manifestations:
 Red, scaly, crusted lesions
 Pruritic
 Can have vesicles
 May have scratch marks
 Involves antecubital fossae, popliteal fossae, neck, areas around
eyes, fronts of ankles
 Dry skin
 Hyper-pigmented for darker skin individuals
o Treatment
  Eliminating exacerbating factors (ie: excessive bathing, low
humidity, emotional stress, overheating of skin, exposure to
detergent)
 Lukewarm baths
 Maintain skin hydration (aquaphor, eucerin)
 Antihistaminescontrol pruritus
 Corticosteriodsdecrease inflammation, if really red/sore
 Antibioticsfor infection
 Dryness is the biggest aggravating factor
 Winter time is the worst
 Urban settingssteam heatvery drying
 Contact Dermatitis
o Inflammation reaction of the skin due to chemical substances
o Usually exposed region (face, neck, back of hands, forearms, lower legs)
o Clinical manifestations:
o Examples:
 Diaper Dermatitis
 Very common
 Prolonged exposure to urine, feces, soap, friction
 Convex surfaces or in folds of skin
o Folds are spared if from urine or feces
o Cloth diapers are a big issue
 Treatment
o Zinc oxide ointmentbarrier to keep moisture out
o Antifungal (Nystatin cream) if progresses to
candidiasis
 Plants (Poison Ivy)
 Irritants (wool, furs, metals, oils, dyes, cosmetics, perfumes,
soaps, etc.)

SKIN DISORDERS DUE TO ANIMAL CONTACT

 Scabies
o Infestation of the skin caused by scabies mite (Sarcoptes scabei)
o More common in wintermites survive longer in cooler temperatures
o Scabies can survive 24-36 hours without human contact
o Increased in crowded conditions
o Transmission from direct contact
o Clinical manifestations:
 Itching (worse at night)
 Small, erythematous papule
 Typically in between fingers, hands & wrist, feet & ankles
 “Hockey stick” presentation
 Scattered, pin-head nodules
 o Treatment
 Permethin (topical) all over body including fingernails, toenails,
behind the ears, etc.
 Applied over night & washed off in the shower the next morning
 Want to treat entire family to prevent re-infestation
 Clothing, bedding, stuffed animals must be bagged for several
days, then washed in hot water, hot dryer, or dry cleaning
 Head lice
o Head louse is gray-white, 3-4 mm insect
o Legs attach to the hair & the mouth sucks blood from the scalp
o Eggs cement firmly to the base of the hair & hatch in 8 days
o Lice survive off the body for 48 hours
o Lice DO NOT jump or fly
o Transmitted from person to person or sharing items (ie: hat, coats)
o Like straight hair
o Clinical manifestations:
 Most are asymptomatic
 Itching can occur
 Nits seen on hair shaft (occipital area), behind the ears, neck
o Treatment
 Topical Pediculicide (Rid, Nix)
 Wash hair with shampoo, rinse, & towel dry
 Apply insecticide cream/gel & leave on for 10 minutes
 Wet comb to remove the lice
 Hot air treatment (30 minutes of hot air)
 Not always covered by insurance
 Homemade remedies don’t work!
 Lyme disease
o Tick borne illness
o Deer ticks
o 2 weeks till symptoms really manifest so treat right away if suspected
o 3 Clinical stages
1. Erythema migrans at site of bite (or within one month of bite)
2. Multiple erythema migrans lesions, some neurological & cardiac
findings
3. Arthritis involving one or a few large joints (ie: knee) and/or
neurological problems (ie: encephalopathy)
o Clinical manifestations:
 EM lesionannular red rings
 Serologic test IgM antibodies & IgG antibodies to B. burgdorferi
o Treatment
 Children under 8 = amoxicillin
 Children over 8 = doxycycline
  Treatment is 14-21 days
 Prevention is important!
 Light colored clothing (so ticks can be spotted)
 Tuck pant legs into socks
 Wear long sleeve shirts tucked into pants
 Perform regular tick checks

NEUROLOGY/NEUROMUSCULAR [5 Questions]

INTRACRANIAL INFECTIONS
 Meningitis
o Acute inflammation of meninges & CSF
o Organism travels from an infection in another part of the body through
the bloodstream to the meninges
 Bacterial Meningitis
o Risk factors
 Recent infection (ear or sinus)
 Close to brain
 Recent exposure to someone with bacterial meningitis
 Respiratory
 Serious head injury
 Hematomablood is stasismeninges can be affected
 Presence of foreign object (cochlear implant, VP shunt)
o MEDICAL EMERGENCY!
o Causative organisms:
 1-3 months
 From mother
 Group B streptococcus
 Gram-negative bacilli
 S. Pneumonia
 Neisseria meningitidis
 3 months-3 years
 Strep/Staph
 S. Pneumonia
 Neisseria meningitidis
 Group B streptococcus
 Gram-negative bacilli
 3 years-10 years
 S. Pneumonia
 Neisseria meningitidis
 10 years-19 years
 Neisseria meningitidis
 Viral Meningitis
 o More common
o Less severe
o Most common is enterovirus
 Spread by direct contact with feces via diapering, contaminated
water, food, & surfaces
 More common between June & October
o Clinical manifestations:
 Fever
 Headache
 Nausea
 Vomiting
 Confusion
 Stiff neck (nuchal rigidity)
 Photophobia
 Rash (generalized throughout body)
 Decreased LOC
 Seizures
 Bulging fontanel
o Diagnostic tests
 Blood culture
 Lumbar puncture
o Treatment
 Treat as bacterial until results are final
 IV antibiotics
 Hydration
 Rest
 PreventionHib, pneumococcal, meningococcal
o Nursing management
 DROPLET PRECAUTION
 Assist with lumbar puncture
 Start IV antibiotics ASAP
 Decrease environment stimuli
 Monitor neurological status & vitals
 IV access for hydration
 Monitor for increased ICP
 Seizure precautions
 Pain management
 Seizures
o Caused by excessive & disorderly neuronal discharges in the brain
o Most common neurological disorders in children
o 2 or more seizures
o Causes:
  Idiopathic
 Secondary to:
 Head trauma
 Hemorrhage
 Anoxia
 Infections/toxins
 Congenital defects
 Hypoglycemia injury
o 3-5% of children will have a single febrile seizure in first 5 years of life
 Do not cause any neurological damage!
 Do not treat with antiepileptic drugs!
o Clinical manifestations
 Depends on area of brain it originated
 Unconsciousness or altered consciousness
 Involuntary movements
 Changes in perception, behaviors, sensations, & postures
o Diagnostic tests
 Neurological exam
 Lumbar punctureinfection
 Blood lead level
 CBC
 Serum blood glucosehypoglycemia
 MRI
 EEG
 CT scan
o Treatment
 Goal is to control the seizures or reduce frequency & severity
 Drug therapy
 Antiepileptic drugs
 Maintain neuronal excitability
 Ketogenic diet
 High-fat, low-carbs, & adequate protein
 Forces body to use fat instead of glucose as primary
energy source
 Vagus nerve stimulation
 Implantable device SQ chest activated by patient or
caregiver at the onset of a seizure
 Delivers electrical impulses to the left vagus nerve
 Surgical therapy
 For refractory seizures only
 Removal of area of brain causing seizure
o Nursing management
 Identify seizure activity
  SAFETY!
 Lower to floor if seizing outside of bed
 Turn on side
 Do not put anything in patient’s mouth
 Rails up (padded) if seizing in bed
 Helmet use
 Swim with close supervision
 Prevent triggers (stress, sleep deprivation, fatigue, fever, &
illness)
 Observe characteristics of the seizure
 Rectal diazepam for prolonged seizure
 Hydrocephalus
o Cerebral vascular system contains excessive CSF & is dilated
(ventriculomegaly) due to increased pressure (brain is compressed)
o CSF accumulates due to imbalance between production & absorption
o May see bulging fontanelnot enough space
o Causes:
 Impaired absorption
 Obstruction in the ventricular system
 Tumor (may increase CSF secretion)
 Neural tube defects (obstruction of 4th ventricle)Arnold Chiari
malformation
 Infections
o Clinical manifestations
 Increased (abnormal) head growth
 Bulging fontanels
 Dilated scalp veins
 Separated sutures
 Frontal enlargement or bossing
 Pupils sluggish & unequal response to light
 Irritability
 Lethargy
 Weak cry
 Changes in LOC
 Vomiting
 Headaches
 Strabismus in older children
o Diagnostic tests
 Head circumference (crosses 1 or more grid lines in 2-4 weeks)
 CT scan
 MRI
o Treatment
  Must drain surgically with a mechanical shunt to minimize
neurological deterioration
 VP shuntallows CSF to drain from the ventricles to the
peritoneum
 This is emergency surgery
 Once this is in…every fever the child gets, must get a
lumbar puncture to rule out infection because they’re at
an increased risk
o Nursing management
 Identify increasing head growth
 Monitor signs/symptoms of increased ICP
 Fever
 Vomiting
 Bulging fontanel
 Irritability
 Lethargy
 Monitor for shunt complications
 Infection
 Mechanical failure (blockage, kinking)

CEREBRAL PALSY
 Most common permanent disability in childhood
 Motor problem
 Brain not able to tell body how to move
 Chronic, non-progressive motor & postural dysfunction (abnormal tone &
coordination)
o But may look worse as they get older
 Associated disorders:
o Visuallow visual acuity
o Epilepsy
o Mental retardation
o Orthopedic disorderscontractures, subluxation, dislocation, & scoliosis
o Growth failuredue to poor nutrition (swallowing disorders, chronic
aspiration)
 Warning signs of CP:
o Poor head control after 3 months
o Stiff arms or legs, increased or floppy tone
o Pushing away or arching backhypertonicity of brain
o Cannot sit up w/o support by 8 months
o Uses only 1 side of body
o Failure to smile by 3 months
o Feeding difficulties
 Hard time sucking & swallowing (one of the FIRST signs)
  Failure to thrive
o Extreme irritability or crying
 Because not feeding
 Primitive reflexes
o Tonic neck reflex
o Grasp reflex
o Step reflex
o Crawl reflex
 Moro Reflex
 4 types
o Spastic (pyramidal)
 Most common
 Diplegia
 Quadriplegia
 Hypertonicity
 Impairment of fine or gross motor skills
 Contractures (most common is heel cord, scoliosis common)
 Gait crouching, in-toeing, scissoring
 Visual deficits
o Dyskinetic (non-spastic, extrapyramidal)
 Athetoid
 Dystonic
 Swaying
 Usually from severe, acute perinatal asphyxia
 Abnormal involuntary movements
 Contractures RARE
 Drooling, impaired speech articulation
 Athetosis: slow, writhing movements of extremities, trunk,
neck, facial muscles, & tongue
 Chorea: irregular, jerking movements
 Dystonia: repetitive patterned, twisting movement of the
trunk & limbs
o Ataxic (non-spastic, extrapyramidal)
 Usually a genetic cause (ie: Joubert syndrome)
 Wide-based gait (unsteady)
 Muscle hypotonicitylack body control
 Speech slurred
 Rapid repetitive movements, performed poorly
 Disturbed coordination
o Mixed type
o Nursing management
 Early recognition
 Habilitation devices (wheelchairs, walkers)
  Medications (Botox/Baclofen)decrease spasticity
 Nutritional supportGT feedings
 Orthopedic surgerycorrect contractures or spastic deformities
 Help reach milestones, good for those with hypertonicity
 Skin assessment
 Parent support

NEURAL TUBE DEFECTS

 Failure of closure of neural tube in embryo
 Associated with low maternal levels of folic acid
 There has been a decrease in this due to prenatal diagnosticsAFP both serum
& amniocentesis, as well as termination of pregnancies
 Spina bifida occulta
o 40% of Americans
o Not visible externally
o L5 & S1
o May only be visible on x-ray
o Clinical manifestations
 No manifestations
 Skin depression or dimple
 Tuft of hair
 Lipomas
 May have neuromuscular disturbances
 Spina bifida cystica
o 90% of time hydrocephalous will develop during infancy
o Meningocele
 Hernial protrusion of saclike cyst of meninges filled with spinal
fluid
o Myelomeningocele
 Hernial protrusion of saclike cyst of meninges, spinal fluid, & a
portion of spinal cord with nervesWORSE
o Clinical manifestations
 Below L2
 Flaccid, partial paralysis of LE
 Lack bowel/bladder control
 Rectal prolapse sometimes
 Below S3
 No motor impairment
 May have bladder & anal sphincter paralysis
o Initial management
 Surgical closure of sac 12-72 hours after birth
 Prior to surgerykeep sac moist & sterile
 Prevent infection
  No rectal temperature
 Neurological assessment
 Cannot have diapers so keeping clean is hard
 Prone position
o Post Neonatal period
 Monitor head circumferencehydrocephalous
 Neurosurgerydevelopment of hydrocephalous & shunt surgery
 Orthopedicsprevent joint contractures, existing deformities,
scoliosis
 GU/GIbowel/bladder control
 OT/PT
o Latex Allergy in 80% of children with SB

GASTROENTEROLOGY [6 Questions]

 Diarrhea
o Acute diarrhea is leading cause of illness in children < 5
o Causes:
 Rotavirus
 Most common viral diarrhea
 New vaccine to decrease incidence
 Bacterial
 More likely to have bloody diarrhea
 Causes:
 Salmonella
 E. Coli
 Shigella
 Campylobacter
o Nursing management
 Prevention!
 Personal hygiene
 Clean water supplyprotect from contamination
 Careful food preparation
 Hand washing
 NO anti-motility agents
 NO antibiotics
 Oral rehydration to prevent dehydration
 Enhances & promotes reabsorption of water & salt
 Na, K, Glucose, & HCL3
 Reduces vomiting, diarrhea, & duration of illness
 Pedialyte is available
 Small volumes
 Can give even if vomitingsmall frequent sips
  Gatorade bad…has lots of sugar=more diarrhea
 Early & gradual reintroduction of nutrients
 Give anti-emetics to stop vomiting, but give nothing to stop
diarrhea because we want the “bad” bacteria/virus to get out &
that’s the only way
 Dehydration
o Total output of fluid exceeds intake
o Types:
 Isotonic
 Water & salt lost EQUALLY
 Primary form of dehydration
 Hypotonic
 Electrolyte deficit
 Hypertonic
 Water deficit
o Percentage of body weight from water = 65%
o Rate of basal metabolism
 Higher BMR in infants & children
 Elevation in BMRfever, dehydration
 Greater fluid requirements than adults
 Need more water to excrete solutes than adults
o Status of kidney function
 Immature kidney functioncannot concentrate urine
 How many diapers?
 Minimum 4-6 wet diapers…if less…concerned
 1 g wet = 1 ml urine
o Clinical manifestations
 Weight loss
 Rapid pulse
 Decreased BP
 Decreased peripheral circulation
 Decreased urinary output
 Increased specific gravity
 Decreased skin turgor
 Dry mucus membranes
 Absence of tears
 Sunken fontanels in infants (should be flat)
o Diagnostic tests
 Most accurate is acute weight loss
 Usually based on clinical symptoms
o Treatment
 Severity dependent
o Nursing management
  IV fluids
 Fluid Requirements: 100, 50, 20 Rule OR 4, 2, 1 Rule
 Lab values
 Low bicarbonate
 Increased H/H
 Skin care
 Specimen collection
 Nutritional assessment
 Hirschsprung’s Disease
o Congential ananglionic megacolon
o Mechanical obstruction from inadequate motility of intestine
 Leads to accumulation of stool with distention
 Failure of internal anal sphincter to relax
 Enterocolitis may occur
o More common in males & in Down’s Syndrome
o Absence of ganglion cells in colon
o Clinical manifestations
 Newborn
 No meconium 24-48 hours after birth
 Refusal to feed
 Vomiting
 Distention (LLQ)
 Infant
 Failure to thrive
 Constipation
 Distention
 Vomiting/diarrhea
 Child
 Constipation
 Ribbon like stool
 Distention
 Palpable mass
o Diagnostic tests
 X-ray after enema
 Rectal biopsyto confirm
o Treatment
 Surgery
 May need temporary ostomy
o Nursing management
 Pre-operative care
 NPO
 Bowel prep
 Antibiotics
  Post-operative care
 Assessment
 Ostomy care
 Diet per orders
 Discharge care
 Ostomy care/teaching
 Return for 2nd surgery
 Gastroesophageal Reflux (GER)
o Gastric contents into the espohagus
o 50-70% of infants less than 2 months of age
o Resolves spontaneously
o More common in Down’s Syndrome, CF, & Muscular dystrophy
o Clinical manifestations
 Infants
 Regurgitation
 Vomiting
 Crying
 Irritability
 Poor feeding
 Upper respiratory infection
 Preschoolers
 Regurgitation
 Upper respiratory infection
 Wheezing
 Poor PO intake
 Sandifer syndromearching back & neck while lifting
chin
 Older children
 Heartburn
 Esophagitis
 Hoarsenessfrom reflux
 Epigastric pain
o Treatment
 H2 receptor antagonist (Zantac, Tagament)block action of
histamine on parietal cells in the stomach, decreasing the
production of acid by these cells
 PPI (Nexium, Prevacid)reduce gastric acid production
 Nissen fundoplication
 Suture fundus of stomach behind esophagus
 Wrap stomach around esophagus so the food cannot
regurgitate back up
 Acute Appendicitis
o Inflammation of vermiform appendix, obstruction
 o Most common requiring surgery
o Clinical manifestations
 Vomiting
 Fever
 RLQ pain
 McBurney’s point
 Periumbilical pain
 Rebound pain
 Anorexia
 Irritable, uncomfortable, apprehensiveJump test
 Sudden relief from pain could occur after perforation!
o Diagnostic tests
 CT scansee if appendix is inflamed (but lots of radiation)
 Ultrasound
o Nursing management
 Surgical removal
 Laproscopy vs. laparotomy
 Pre & post operative care
 Antibiotic therapy
 Possible NG tube placement
 Pain management
 Can have appendicitis againthere is a “stump” that can get
infected
 Cleft Lip and/or Cleft Palate
o Facial malformations during early embryonic development (5-9 weeks)
o Lip and/or palate do not fuse
o Associated with chromosomal anomalies (Pierre Robin Syndrome)
 Also heart defects, ear malformations (“dimples” in front of ears),
skeletal deformities, GU abnormalities (want to look at kidneys)
 Associated risk with maternal smoking, prenatal infection,
advanced maternal age, medications during early pregnancy
o Management
 Surgical closure or lip defect precedes correction of the palate
 Plastic surgery
 Craniofacial specialists
 Oral surgery
 Dental & orthodontist
 Audiology/Speech Therapy
 Psychology
 Feeding issues: use bottles with specialized nipples (Haber)
 Firm tip (in place of hard palate)
 Prevent injury to suture line
 Place in supine or side lyingmay need restraints
  Avoid putting items in the mouth
 Prevent crying
 Hypertonic Pyloric Stenosis
o Hypertrophy of the pylorusleads to constriction of pyloric sphincter
with obstruction of gastric outlet
o Presents in first 2-5 weeks of life
o Common in males
o Clinical manifestations
 PROJECTILE VOMITING
 Needs to be re-fed (immediately hungry)
 Can lead to dehydration, electrolyte imbalances, & poor weight
gain
 Palpable olive shaped mass in RUQ
o Diagnostic tests
 Sonogram to officially diagnosefeed them to see if it can pass
o Management
 Surgical correction
 Nissen fundoplication
 Pre & post operative care
 Rapid recoveryfeeding within 4-5 hours
 Intussusception
o One portion of intestine into another
 Usually where large & small bowel meet
o Usually due to intestinal lesions
o Cause is often unknown
o More common in males, 3-9 months, may occur up to 6 years
o Clinical manifestations
 Colicky abdominal pain (knees to belly)
 Abdominal mass: “Sausage shaped”
 Currant jelly stools
 Late sign from edema, mucus, irritation, & leaking of blood
 Vomiting
o Diagnostic tests
 Ultrasoundlooking into bowel, donut appearence
 Abdominal series of x-rayslook for flow of gas, won’t see
flowing through the whole colon
o Management
 Air enema
 Ultrasound guided saline enema
 Non-operative reduction
 NPO
 NG tub for decompression
 Assess stooltest for blood
  If enema doesn’t work…may need to go to surgery
 Celiac Disease
o Gluten-induced enteropathy & celiac sprue
o Autosomal recessive disorder
o Exposure to gluten causes inflammatory response in intestinal mucosa,
atrophy of intestinal villus
o Results in malabsorption
o 4 main characteristics
 Steatorrhea
 General malnutrition
 Abdominal distention
 Secondary vitamin deficiencies
o Other clinical manifestations
 Short stature
 Vomiting
 Delayed puberty
 Anemia
o Diagnostic tests
 Biopsy of small intestines
 Immunologic & genetic studies
o Management
 Management of acute symptoms
 Dehydration
 Electrolyte imbalance
 Impaired nutrition
 Possible anemia
 Diet modifications
 Gluten-free
 Within a few days should have improved appetite & gain
weight
 Within a few weeks diarrhea & steatorrhea resolve
 High in calories & proteins
 Increased fruit & vegetables

GENITOURINARY [4 Questions]

 UTIs
o Lower urinary tract (urethra & bladder) or Upper urinary tract (ureters,
renal pelvis, calyces, & renal parenchyma)
o Acute pyelonephritiscan lead to renal scarring, HTN, & end-stage renal
disease
o Most common during 1st year of life, potty training (bad wiping), &
teenage girls
o Contributing factors
 Short urethra
 Urinary stasis
 Reflux (bladder urine into the ureters)
o Clinical manifestations
 Infancy
 Poor feeding
 Vomiting
 Failure to thrive
 Frequent urination
 Foul-smelling urine
 Pallor
 Fever
 Persistent diaper rash
 Childhood
 Abdominal pain (suprapubic tenderness)
 Frequency & urgency on urination
 Dysuria
 Poor appetite
 Vomiting
 Growth failure
 Excessive thirst
 Enuresis/incontinence
 Swelling of face
 Pallor
 Fatigue
 Back pain
 Blood in urinelate sign
o Diagnostic tests
 Urine culture (sterile)
 Sterile catheterization
 Suprapubic aspirationused instead if there are
adhesions
 Clean catch
 Urinalysis
 Leukocytes
 Nitrates
 Blood
 If urine culture positivemay need renal ultrasounds and/or
VCUG
o Treatment
 PO antibiotics
  Less than 2 years oldmay need to be admitted & put on IV
antibiotics
 May need surgical correction
 Nephrotic Syndrome
o Most common glomerular injury in children
o Congenital/genetics & secondary to lupus
o Characteristics
 Proteinuria
 Frothy & foamy urine
 Hypoalbuminemia
 Hyperlipidemia
o Clinical manifestations
 Weight gain
 Facial edema (especially when waking up)SWOLLEN EYES
 Abdominal swelling
 Diarrhea
 Anorexia
 Easily fatigued decreased urine volume
o Diagnostic tests
 Urinalysis 3+ protein
 24 hour urine >50mg/kg/day
 Low serum albumin
 Low serum protein
 Renal biopsy
o Treatment
 Goal is to reduce excretion of urinary protein
 Want to reduce fluid retention
 Dietary restrictionslow salt
 Fluid restrictions
 Sometimes diuretic therapy in severe cases
o Nursing management
 Monitor fluid retention or excretion
 Strict I & O
 Urine examination for protein (UA dipstick)
 Daily weight & measurement of abdominal girthto check for
fluid retention & swelling
 Monitor vitals
 Parent education
 Acute Glomerulonephritis
o Usually from post-infection
 Pneumococcal
 Streptococcal
  Viral
o Peak age is 6-7
o More common in winter & spring
o Most recover completely
o Clinical manifestations
 Edema (especially periorbital)
 HTN
 Hematuriatea colored urine
 Proteinuriathe more there is, the worse the severity of renal
disease
o Symptoms
 Generalized edemadue to decreased glomerular filtration
 Loss of appetite
 Decreased urinary output
 Progresses to lower extremities & then to ascites
o Treatment
 Dietary restrictions
 Moderate salt
 Fluid restrictions
 Vital signs, daily weights, I & O
 Wilm’s Tumor
o Aka nephroblastoma
o Malignant renal & intra-abdominal tumor
o 90% survival rate
o Peak age = 3
o More common in males
o Associated with GU anomalies & syndromes
o Clinical manifestations
 Increased abdominal girthfirm & non-tender to 1 side
 Hematuria
 HTN
 Fatigue
 Weight loss
o Treatment
 Surgical removal
 Chemotherapy
 Radiation
o Nursing management
 NO ABDOMINAL PALPATION!
 Manipulation of tumor can cause spread of cancer cells to
cells nearby
 Monitor BPare at increased risk for HTN
 Client & family teaching/support
  Surgery is performed 24-48 hours after diagnosis
 Chemotherapy immediately after surgery

HEMATOLOGY/ONCOLOGY [6 Questions]

RED BLOOD CELL DISORDERS

 Iron Deficiency Anemia
o Inadequate supply of dietary iron
o Generally preventable (iron-fortified cereals/formulas)
o Adolescents at increased risk because of rapid growth & poor eating
habits
o Symptoms
 Fatigue
 Pallor
o Treatment
 Increase iron intake (food)
 Beef, clams, oysters, turkey, chicken, fish
 Bok choy, brussel sprouts, broccoli
 Dried fruits
 Iron supplements
 Do not take with milk
 Can cause constipation
 Take with citric acid
 Change in stool color & consistency
 Stains teeth (brush after taking)
 Sickle Cell Anemia
o Autosomal recessive disorder
o Common in African Americans
o Partial or complete replacement of normal Hgb with abnormal Hgb S
o Sickle cells are rigid & obstruct capillary blood flow
o Microscopic obstructions lead to engorgement & tissue ischemia
o Hypoxia occurs & causes sickling
o No cure
o Bacterial infection is leading cause of death in young children with sickle
cell disease
o Every time they get a fever they must come it
o Sickle Cell Crisis
 Acute exacerbations that vary in severity & frequency
 Vaso-occlusive thrombotic
 Most common typevery painful
 Stasis of blood with clumping cells in
microcirculationischemiainfarction
o Risk factors (Sickle Cell Crisis)
  Anything that increases body’s need for oxygen or alters transport
of oxygen
 Trauma
 Infection, fever
 Physical/emotional stress
 Increased blood viscosity caused by dehydration
 Warm packs to move blood along…NEVER ICE PACKS!
 Hypoxia
o Crisis management
 Promote oxygenation
 Reduce sickling
 Reduce/eliminate pain
 Prevent/treat infection
 Conserve energy (reduce O2 demand)
o Sickle Cell Disease Management
 IV therapy
 Pain management
 Oxygen therapy
 Electrolyte replacement
 Warm to joints
 Blood transfusion as indicated
 May result in hemosiderosis (iron in tissues)
 Treat with iron chelation & vitamin C to promote iron
excretion
 Hydroxyureadecreases production of abnormal blood
cells & decreases pain
 Post crisis: vaccination (pneumococcal & meningococcal) &
antibiotics

NEOPLASTIC DISORDERS
 Leading cause of death in children past infancy
 Leukemia
o Malignant disease of bone marrow & lymphatic system
o Unrestricted proliferation of immature WBCs in the blood-forming tissue
of the body
o Types:
 ALL
 80% survival
 AML
 50% survival
o Most frequent in males
o Peak onset between 2-5
o Physical manifestations
  Weight loss
 Fever
 Frequent infections
 Easily SOB
 Weakness
 Pain or tenderness in bones/joints
 Fatigue
 Loss of appetite
 Swelling of lymph nodes
 Enlargement of spleen or liver
 Night sweats
 Easy bleeding or bruising (concerned when on back of arms,
buttock, or thighs)
 Petechiae
o 3 major consequences
 Anemia
 Infection
 Bleeding
o Diagnostic tests
 History & physical
 Peripheral blood smear
 Immature leukocytes
 Frequent low blood counts
o Treatment
 Chemotherapy (4 stages)
 Side effects:
 Anemia
o Decreased RBC production
o Fatigue, pallor
o Decreased O2 carrying capacity
 Thrombocytopenia
o Low platelets
o Increased risk for bleeding
o Soft toothbrushes
o Avoid injections/blood draws
o Observe for bruising
o Observe gums/nosebleeds
o May need possible transfusion
 Neutropenia
o Low WBC, low neutrophils
o Increased risk for infection
o Hand washing!
o Visitor restriction if possible
 o Vaccinations as appropriate
o Avoid flowers, non-peeled fruits, cook all
vegetables
 Pancytopenia
 Changes in diet/taste/appetite
 Stomatitis
 Hair loss (alopecia)
 Mood changes
 Nausea/vomiting
o Anti-emetics PRIOR to chemotherapy
o Observe for dehydration
o Small meals
o Carbonated beverages (makes them feel
better)
 Mouth ulcers
o Soft diet
o Normal saline & baking soda rinse
o NO alcohol based rinse
o Magic mouth wash = Malox & Benadryl
 Administration sites
 PICC line
 PIV
 Central Venous Internal Line: Port
 External Catheter: Hickman
o Dressing changes, make sure clean
 Careful handling
 Must be certified
 “Vesicants”sclerosing agents even in small amounts
 Risk for anaphylaxis
 Stem cell transplant
 Radiation