Families Exam 2 : Hematologic, Cardiovascular, Respiratory, Pain Management, and Child Maltreatment

Iron Deficiency Anemia: What is it? Risk Factors? Precipitating Conditions? Assessment Findings? Lab Tests? and Management?

What is it? Is the most prevalent heme disorder

Risk Factors: premature birth, excessive intake of cows milk, poor dietary intake of iron, blood loss

Precipitating Conditions: Infants - GERD, pyloric stenosis; Older Kids - GI polyps, colitis; Teens: menorrhagia

Assessment Findings: tachycardia, pallor, brittle spoon shaped nails, fatigue, muscle weakness, systolic heart murmur, pica

Lab Tests: CBC w diff, reticulocyte count, total iron binding capacity, transferrin, stool analysis (Guaiac test)

Management: iron-rich foods/supplements!!! (give 1 hr before or 2hrs after breast milk)

Idiopathic Thrombocytopenic Purpura: What is it? Risk Factors?

What is it? Thought to be caused by an inc in platelet destruction. Manifestations begin abruptly --> miniature petechiae or large areas of asymmetric ecchymosis (usually over the legs). Platelet count can be as low as 20k (should be 150k). Causes bleeding, joint pain, epistaxis

Risk Factors: recent viral illness, unvaccinated, or mom had ITP during pregnancy

What should you NEVER give to a pt with ITP?

Ibuprofen! -> Prevents platelet aggregation/function

Sickle Cell Anemia: What is it? Assessment Findings? Complications? Labs?

What is it? Abnormal sickle hemoglobin replace normal adult hemoglobin. Erythrocytes are elongated and crescent shaped when submitted to low O2 tension, low pH, or dehydration. Complications of blood sickling --> inc blood viscosity, obstruction of blood flow, and tissue hypoxia

Assessment Findings: pain, SOB, fatigue, pallor, pale mucous membranes, jaundice, extremities cool to touch, dizziness, HA.

Labs: CBC, Sickle-turbidity, Hemoglobin Electrophoresis

What is a Vaso-occlusive Crisis? Difference between an Acute and Chronic Crisis? Lab findings?

It is a sudden, severe onset of sickling (usually caused by dehydration, dec O2 level, or strenuous exercise). Pooling of sickled cells --> SEVERE PAIN!!

Acute Crisis: SEVERE pain in swollen joints, bones, or abdomen, hematuria, obstructive jaundice, and visual disturbances.

Chronic Crisis: inc risk of respiratory infections and osteomyelitis, retinal detachment/blindness, systolic murmurs, renal failure and enuresis, liver cirrhosis/hepatomegaly, seizures, and skeletal deformities

Labs: decreased Hgb, elevated WBC, Elevated bilirubin and reticulocytes, and sickled cells on blood smear

What is a Sequestration Crisis? Complications? Treatment?

What is it? Excessive pooling of blood (usually in the spleen and maybe the liver) --> severe anemia!

Reduced circulation blood volume --> hypovolemia--> shock!

Complications: stroke, acute chest syndrome, infections, kidney scarring, dec visual acuity, priapism

Treatment: REST!! dec O2 consumption, exchange transfusion, intense hydration therapy, and pain management

What is used to increase fetal Hb levels to prevent sickling?

Hydroxyurea: it increases hemoglobin F --> helps RBC stay round and flexible; can reduce painful crises!! **Also can be used to treat leukemia**

Hemophilia: What is it? Assessment Findings? Lab Findings? Therapeutic Management?

What is it? group of hereditary bleeding disorders that result from deficiencies of specific clotting factors. (Hemo A: factor VIII, Hemo B: factor IX, Von Willebrand: factor VIII and VW factor. )

Assessment Findings: bleeding (literally everywhere lol), joint pain and stiffness (hemarthrosis), easily bruised, impaired mobility.

Lab Findings: Prolonged partial thromboplastin (aPTT), factor-specific assays, platelets, prothrombin time, and whole blood clotting time are within NORMAL ranges.

Therapeutic Management: replace missing clotting factors, Desmopression (DDVAP), and Aminocaproic Acid.

What should NEVER be given to pt with Hemophilia?

Aspirin!! Acetaminophen is acceptable substitute for pain!

Leukemia: What is it? Risk Factors? Lab Tests? Diagnostic Procedures?

What is it? Malignancy that affects the bone marrow and lymphatic system --> increase in the prod. of immature WBCs --> decline of RBCs and platelets. Peaks btwn 2 and 5 years of age.

Risk Factors: male, white or hispanic, family Hx, trisomy 21.

Lab Tests: anemia, thrombocytopenia, neutropenia, leukemic blasts and blood smear (immature WBCs)

Diagnostic Procedure: BONE MARROW BIOPSY (done in iliac crest or spine!), cerebral spinal analysis, liver & kidney function studies

Difference between Early and Late manifestations of Leukemia?

Early: low-grade fever, pallor, lethargy, inc bruising and petechiae, enlarged liver, lymph nodes, and joints, V and anorexia, constipation, HA, unsteady gait

Late: pain, hematuria, ulcerations in mouth, enlarged kidney and testicles, manifestations of inc intracranial pressure (bc one of the biggest pockets of bone marrow is in the frontal bone!)

Complications of Leukemia?

Infection, hemorrhage, anemia, CNS effects (blindness, hydrocephalus, recurrent seizures), kidney impairment (inc uric acid --> obstructs renal tubules --> dec excretion of chemotherapy agents) ***Allopurinol is given to dec uric acid production

Cardiac Diagnostic Tests?

Electrocardiogram (ECG): 1st line diagnostic tool that detects arrhythmias, conduction delays (firing cells), and chamber enlargement

Echocardiography Imaging: non-invasive visualization of cardiac structure and function to diagnose congenital defects

Cardiac Catheterization: measures intracardic pressures and O2 sats

ECHO: ultrasound to visualize the structure/function of the heart (looks at ejection fraction and anatomy)

Newborn Screening for Critical Congenital Heart Disease?

Method: pulse oximetry; measures pre-ductal (R hand) and post-ductal (either foot) O2 sat after 24hrs of life to ensure accuracy and detect abnormalities

-A saturation of less than 90% is an automatic FAIL; readings between 90-94% indicates the need for repeat testing

**Most common in testing for Ductus arteriosus!

Heart Murmurs: Innocent vs Pathologic? How to properly document a murmur?

Innocent: soft, vibratory, short systolic sounds (common in young children due to thin chest walls and high CO)

Pathologic: harsh or blowing quality, diastolic timing --> indicates structural heart defects w/ associated symptoms (cyanosis, syncope, or failure to thrive)

Documentation: must include timing, intensity, location, radiation, quality, and associated findings

**Intensity is graded using the I-VI Levine Scale (I is barely audible and VI is heard w/o a stethoscope)

Patent Ductus Arteriosus: What is it? Assessment Findings? Risk Factors? Nursing Interventions?

What is it? Fetal shunt fails to close after several days of life --> blood flows from the aorta thru the PDA to the main pulmonary artery (causes oxygenated blood to flow BACK into the lungs instead of the body!!)

Assessment Findings: early systolic murmur w/ no resolution, rales, congestion, inc WOB, difficulty feeding

Risk Factors: congenital

Nursing: give diuretics, inc calories at feeds, may need surgery (NSAIDs can help close the vessel)

Ventricular Septal Defect: What is it? Manifestations? Management?

What is it? A congential hole btwn ventricles --> causes left-right shunting and inc pulmonary flow (volume overload!)

Manifestations: tachypnea, sweating while feeding, irritability, poor weight gain, harsh holosystolic murmur at L lower sternal border (clinical diagnosis of VSD!!)

Management: diuretics/ACE inhibitors, surgery, monitor feeding tolerance, daily weights, respiratory efforts, and signs of heart failure

Atrial Septal Defect: What is it? Manifestations? Treatment?

What is it? A defect in the atrial wall allowing oxygenated blood from the L atrium to flow into the R atrium. A true tissue deficiency! L-to-R shunting causes R atrial and ventricular dilation

Manifestations: fatigue, exercise intolerance, and a classic heart murmur. **May be asymptomatic until older!

Treatment: catheter-based closure or surgical patch repair

Nursing Care: Monitor for arrhythmias, manage pain, prevent infections

Tetralogy of Fallot: What is it? Manifestations? Treatment? Nursing Care?

What is it? Consists of 4 anatomical defects: ventricular septal defect, pulmonary stenosis, overriding aorta, and R ventricular hypertrophy.

All of these defects produce R-to-L shunting and reduced pulmonary blood flow --> cyanosis!

**Hallmark of TOF is the occurrence of hypercyanotic or "Tet spells" --> triggered by crying, feeding, or agitation

Manifestations: Tet spells, cyanosis, clubbing, harsh systolic murmur

Treatment: knee-to chest position for acute management; may need surgery

Nursing Care: manage Tet spells!!

Coarctation of the Aorta: What is it? Manifestations? Managment?

What is it? A narrowing of the descending aorta --> restricts systemic blood flow and significantly INCREASES afterload --> elevated BP in upper extremities and hypo-perfusion in lower extremities **diminished femoral pulses and BP differences are a key sign!

Manifestations: poor feeding, distress, headaches, nosebleeds, leg pain on exertion

Management: administering prostaglandin E1 to maintain ductal patency until surgical repair or ballon angioplasty can be done

Rheumatic Fever: What is it? Criteria for Diagnosis? Prevention?

What is it? An autoimmune inflammatory condition --> develops from untreated Group A streptococcal pharyngitis --> antibodies attack heart, nerves, and joints after a strep infection

Diagnosis: REQUIRES 2 major or 1 major plus 2 minor symptoms

**major symptom = carditis, polyarthritis, chorea, subq. nodules, and erythema marginatum

**minor symptoms = fever, elevated inflammatory markers, and prolonged PR interval

Prevention: COMPLETE ANTIBIOTICS and long-term penicillin prophylaxis is ESSENTIAL!!!

Kawasaki Disease: What is it? Diagnosis?

What is it? An acute systemic vasculitis; effects kids under 5 yo --> significant risk of coronary artery aneurysms if untreated!!

Diagnosis: Fever lasting at LEAST 5 days in combo w/ 4/5 clinical features: bilateral non-purulent conjunctivitis, strawberry tongue/cracked lips, polymorphus rash, extremity swelling/peeling, and cervical lymphadenopathy.

Treatment: high dose of IVIG and aspirin

**Avoid live vaccines for several months post IVIG

Cardiomyopathy: What is it? Manifestations? Risk Factors? Management?

What is it? Structural or functional abnormalities of the myocardium that impair the hearts ability to pump (dilated, hypertrophic, adn restrictive)

Manifestations: fatigue, dyspnea, exercise intolerance, syncope, or arrhythmias

Risk Factors: genetic, viral infections, metabolic diseases, and muscular dystrophies

Management: ACE inhibitors. beta blockers, diuretics, anti-arrhythmic agents

Myocarditis: What is it? Manifestations? Management?

What is it? inflammation of the myocardium, which is most commonly caused by enterovirus or adenovirus ; impairs myocardial contractility --> rapid-onset heart failure

Manifestations: arrhythmias or cardiogenic shock

Risk Factors: recent viral and autoimmune disorders

Management: Fluid restriction!! Encourage rest to reduce cardiac workload

Acute pain occurs bc of 4 reasons:

1. Reduced pH alterations

2. Pressure on tissues

3. External Injury

4. Overstretching

4 Types of Pain?

1. Cutaneous (superficial)

2. Somatic (muscle and bones)

3. Visceral (internal organs)

4. Referred (perceived far from point of origin)

Signs of pain in Infants?

Guarding, grimacing, crying, sleep disruption, holding still/tense abdomen, tachycardia, vigorous body movements

Pain when dealing with toddlers/preschoolers?

Use comfort measures, they have little to no concept of time, may show signs of regression/withdrawal, egocentric thinkers (they assume you know they're in pain!!)

Pain when dealing with school-aged and adolescents?

Still egocentric thinkers! Are able to rate pain, can still show signs of regression, may have verbal outburst or nonverbal cues of pain

Pain Assessment Tools for INFANTS

FLACC: facial expression, leg movement, activity, cry, console

CRIES: crying requires oxygen supplementation, increased VS, expression, sleeplessness

NIPS: cry, facial expression, breathing patterns, positioning of arms/legs, state of arousal

Pain Assessment Tools for TODDLERS

Wong-Baker Faces Pain Scale

Oucher Pain Rating Scale

Developmental Milestones

Infants: rolling, sitting, babbling, social smile

Toddlers: walking, 2-3 word phrases, parallel play

Preschoolers: hopping, sentences, imaginative play

School-aged: reading, friendships, team play

Adolescents: puberty, identity, abstract thinking

Developmental Screening Tools

ASQ: monitors milestones

M-Chat: screens for autism @ 18 and 24 months

Vision and Hearing: begins in preschool

Scoliosis: school-aged

Red Flags for Ophthalmology Referral

1. asymmetry in red reflex or corneal light reflex

2. Failure to fix and follow by 3 months

3. Strabismus after 6 months

Programs at the Child Advocacy Center

Child Protection Team: provides diagnosis in child abuse investigations

Children's Advocacy Center: provides the child and non-offending caregiver support throughout the investigation

The Healing Tree: provides counseling for physical & sexual abuse victims and families

What is a sentinel injury?

An injury that appears minor but can be a precursor to something more serious

What is a torsional loading force?

Spiral fracture: occurs when a twisting force is applied to the bone while one end remains fixed --> breaks!

What is Munchausen by Proxy Syndrome/Medical Abuse?

a serious form of abuse where a caregiver fabricates/exaggerates, or even induces physical or mental illness to the person they are taking care of (usually done to gain attention or sympathy from medical professionals or their community)

What sinuses are present at birth? Which develop btwn 3-7years?

Ethmoid and maxillary; sphenoid and frontal

Nasopharyngitis: What is it? Manifestations?

What is it? Upper respiratory infection "The Common Cold", usually viral, occurs 8-12x a year lasting 7-10 days

Manifestations: nasal congestion, watery rhinitis, fever, posterior rhinitis (post nasal drip), swollen lymph nodes

**Give Tylenol/ibuprofen but avoid cough and cold meds for kids younger than 6 years old and AVOID ASPIRIN --> Reye's Syndrome

Pharyngitis: What is it? Caused by? Treatment?

What is it? Inflammation of the pharynx; usually viral (causes red, swollen mouth/ **yellowish white spots when bacterial)

Caused by: Strep A, allergies, postnasal drip, trauma, reflux

**bacterial strep can lead to scarlet fever!

Treatment: penicillin, 1st gen cephalosporin

Laryngotracheobronchitis "Croup": What is it? Manifestations? Treatment?

What is it? Inflammation of the larynx, trachea, and major bronchi; usually viral

Manifestations: Barking cough (usually @ night), inspiratory stridor, hoarseness, retractions, Steeple Sign

Treatment: inhaled/nebulized corticosteroids or PO corticosteroid, humidified air, and fluids

**ALWAYS rinse mouth after inhaling corticosteroids --> can cause thrush!

Influenza: What is it? Most severe at what age? When is vaccine given?

What is it? Inflammation of the airways of the lower resp. tract. Usually viral; MOST SEVERE in kids under 5 especially under 2 years old

Vaccine is given starting @ 6 months old

Bronchiolitis: What is it? Manifestations? Management?

What is it? inflammation and edema of the bronchioles; usually viral (EXTREMELY CONTAGIOUS!!!) RSV is the most common cause!!

Manifestations: Cough, wheeze, retractions, nasal flaring, poor feeding, fever, resp. distress, may cause hypoxia if severe ... can last up to 2 weeks (worst symptoms day 3-5)

Management: Mild --> antipyretics, hydration, nasal saline, suction, cool mist humidifier

Severe --> O2 supplementation, humidified high flow O2,

Bronchitis: What is it? Manifestations?

What is it? Inflammation of the major bronchi; usually viral (influenza, adenovirus) but can be bacterial (Mycoplasma pneumoniae)

Manifestations: fever, hoarse cough/mildly productive, rhonchi, coarse crackles, rales, hyperinflation (flat diaphragm)

Asthma: What is it? Manifestations? Nursing Interventions? Medications?

What is it? Chronic inflammation of the respiratory tract; MOST COMMON chronic illness in children (difficult to diagnose before 5 years old bc of constant URIs). Could be viral or environmental

Manifestations: expiratory wheeze, chest tightness, hoarseness, cough

Nursing Interventions: monitor peak flow rate and educate pt to avoid triggers

Medications: Quick Relief --> albuterol / Long-Acting Relief --> fluticasone (used daily)

**ALWAYS rinse mouth after inhaling corticosteroids --> can cause thrush!!

**Status asthmaticus is the failure to respond to medications --> may need IV steroids

Cystic Fibrosis: What is it? Manifestations?

What is it? A genetic disorder of the secretory glands that causes thick secretions in the pancreas and lungs **Prenatal Screening

Manifestations: frequent respiratory infections, unable to absorb milk fat (failure to gain weight), sweaty/salty skin, steattorhea

Treatment: hydration, nutrition, humidify, chest physiotherpay

Epiglottitis: What is it? Manifestations?

What is it? MEDICAL EMERGENCY!!!! Inflammation of the epiglottis and surrounding structures --> blocks the airway!! **Was usually caused by HiB before the vaccine was made

Manifestations: appears to be a URI but progresses into a high fever, dysphagia, drooling, muffled voice, stridor, tripoding

**NEVER USE DEPRESSOR TO VISUALIZE THE AIRWAY!! --> May cause laryngospasm if they have a gag reflex

Pertussis: What is it? Manifestations? Vaccine Schedule?

What is it? "Whooping Cough", bacterial infection

Manifestations: severe cough with a "whooping" sound, vomiting, apnea, cyanosis

Treatment: vaccine, antibiotics, hydration

**Contagious for 5-7 days when given antibiotics but can last WEEKS if not!!!

VACCINE (Tdap) is given at abt 11-12 years of age and is given a booster shot 10 years after the first

Pneumonia: What is it? Manifestations? Treatment?

What is it? Infection of the lungs leading to inflammation, alveolar consolidation, and impaired gas exchange; usually viral (RSV, parainfluenza), but can be bacterial (Strep pneumonia, Hib) or atypical (Mycoplasma)

**Inc risk if premature baby (they have underdeveloped lungs), chronic lung or cardiac disorders, and exposed to smoke

Manifestations: fever, irritability, nasal flaring, grunting, retractions, crackles, wheezing, hypoxia, cyanosis, dehydration, and poor feeding (they cant suck, swallow, and breathe properly!)

Treatment: monitor O2 and airway, keep them hydrated, give antibiotics or antivirals and ensure they COMPLETE THE COURSE OF TREATMENT!!!!

What are the early and late signs of respiratory distress?

Early: tachypnea, nasal flaring, retractions, restlessness, irritability

Late: grunting, cyanosis, decreased LOC, apnea

MMR Infections: What are the illnesses and when is the vaccine given?

Measles: very contagious viral illness, causes a maculopapular rash, spread through direct contact of droplets or airborne; the 3 C's (Cough, Coryza, and Conjunctivitis.. also Koplik Spots)

Mumps: contagious viral infection of the parotid gland

Rubella: milder version of measles, causes discrete pink-red maculopapular rash on face --> trunk--> extremities

VACCINE should be given twice: once at 12-15 months then again at 4-6 years old

Varicella (Chickenpox): What is it and when is the vaccine given?

What is it? is a highly contagious viral illness that causes macules, papules, and vesicles to appear all over the body, starting at the trunk and spreading to the extremities --> lesions eventually crust over

VACCINE is given twice: once at 12-15 months then again at 4-6 years

Polio: What is it and when is the vaccine given?

What is it? is a contagious viral infection that is spread thru the fecal-oral route; it can lead to severe disability, paralysis, and even death!

VACCINE is a 4-dose series @ 2 months, 4 months, 6-18 months, and 4-6 years

Infectious Mononucleosis: What is it? Manifestations?

What is it? Viral illness caused by EBV; acquired from direct contact of saliva

Manifestations: fever, cervical adenopathy, pharyngitis w/ palatal petechiae, abdominal pain, hepatosplenomegaly (inc risk of rupture!!!)

**Can only be managed with pain and fever meds :(

Erythema Infectiosum "Fifth Diease" : What is it? Manifestations?

What is it? generally mild, highly contagious viral infection caused by Parvovirus

Manifestations: "slapped cheek" exanthem, circumoral pallor