Peds Exam 3 Combined

What does GCS measure:

• 3 levels

LOC:

1. eye opening

2. verbal response

3. motor response

• 13+: normal or mild brain injury

• 9-12: moderate injury

• < 8: severe brain injury/ coma

LOC and their meanings: (5)

1. Alert: use normal voice

• awake, answers appropriately

2. Lethargic: use loud voice

• Drowsy, but responds to voice and falls asleep easily

3. Obtunded: shake gently

• confused, decreased awareness in surroundings

4. Stupor: painful stimuli

• only responds to pain

• minimal verbal response

5. Coma: repeated painful stimuli

• doesn’t respond to any stimuli

What info needs to be assessed with headaches- basic? (6)

• basically OLDCARTS

1. onset/pattern

2. frequency/severity over time

3. location

4. associated s/s

• migraines accompanied by GI changes

5. triggers

6. stress level

• school, fam, homework

HA red flags: (10)

1. sudden, severe HA

2. increasing severity

3. HA in ONE location only

4. HA wakes child from sleep

5. worse when coughing/sneezing or Valsalva maneuver

6. papilledema

7. unilateral weakness

8. diplopia

9. imbalance

10. seizures

Whats meningitis?

• caused by (2)

inflamed meninges surrounding brain + spinal cord

• caused by viral or bacterial infx

What can cause meningitis? (3)

1. skull fractures

2. crowded spaces (dorms)

3. penetrating head wounds

Difference b/w viral and bacterial meningitis:

1. CSF:

2. WBC:

3. Protein:

4. Glucose:

5. Gram stain:

Viral: (milder)

1. CSF: clear

2. WBC: slightly high

3. Protein: normal

4. Glucose: normal

5. Gram stain: negative

Bacterial: (can be fatal)

1. CSF: cloudy!

2. WBC: high!

3. Protein: high!

4. Glucose: LOW

5. Gram stain: positive

Meningitis s/s newborns (7)

1. NO nuchal rigidity!! (neck is supple/flexible)

2. weak cry

3. bulging fontanel (LATE sign)

4. poor feeding/vomit

5. poor muscle tone

6. poor suck

7. fever or hypothermia

Meningitis s/s infants (3 mon-2yrs): (7)

1. high pitched cry

2. bulging fontanels

3. HAS nuchal rigidity!!

4. photophobia

5. fever/irritable

6. poor feeding/ vomit

7. Brudzinski’s and Kernig’s signs NOT reliable!!!

Brudzinski’s and Kernig’s signs

Brudzinski’s

• A sign of meningitis where the hips and knees automatically bend when neck is bent forward.

Kernig’s

• the leg cant fully straighten b/c of pain and resistance.

Meningitis s/s children-adolescents (2-18 y/o):

• specific (5)

• common (7)

1. + Brudzinski’s sign

2. + Kernigs sign

3. petechiae or purpuric rash (meningococcal infx)

4. joints are involved (Hib and meningococcal infx)

5. chronic ear draining (pneumococcal infx)

common s/s: (7)

1. seizures

2. nuchal rigidity

3. fever/chills

4. HA

5. confused

6. vomit

7. irritable/restless

What is considered a medical emergency and the most severe form of meningitis?

Petechiae!!!!

• means infection reached bloodstream

Nurse care for meningitis: (9)

1. look for petechiae!!! Emergent

2. droplet isolation! ASAP

3. assess bulging fontanel if < 18 mon.!!

4. seizure precautions (suction, padding, turn)

5. correct fluid volume deficit, the restrict fluids till ICP resolved

6. NPO (bc ⬇LOC)

7. quiet, low stim environment

8. no pillow (neck flexion), semi fowlers

9. side-lying

Signs of increased ICP in infants: (4)

1. bulging fontanel

2. ⬆head circumference!

3. high pitched cry

4. distended scalp veins

Interventions to reduce ICP: (5)

1. elevate HOB

2. neutral head alignment

3. no coughing/straining

4. quiet dark room

5. limit suctioning

what are:

• tonic clonic seizures

• myoclonic

• absence seizures

• atonic

• tonic clonic seizures:

  • body stiffens w/ jerking movements

    • loss of LOC and control of bladder, tongue biting

• myoclonic

  • quick muscle jerks; person conscious

• absence seizures

  • brief loss of awareness where they stare into space

• atonic

  • muscle suddenly lose strength (collapse or drop)

What are Febrile seizures

d/t infx causing high fever >101 F in children 5 mon.-6 yrs

• lasts for 15-20 secs

Causes for seizures in neonates: (6)

1. hypoxia

2. intracranial hemorrhage

3. birth injury

4. metabolic disorders

5. hypoglycemia

6. kernicterus

Whats kernicterus and how to prevent it?

→ severe neonatal jaundice where bilirubin accumulates and enters brain= damaged brain cells

• phototherapy!!

3 stages of seizure:

1. aura: warning sensation

2. ictus: actual seizure

3. postictal: after seizure (recovery)

Nursing care during seizure: (4)

1. airway patency (no loose tooth)

2. O2 >95%; pink skin

3. IVP meds slowly (prevent resp or circulatory failure)

4. raise and pad side rails/floor

Whats Reye Syndrome?

• who does it affect? (2)

• rare condition causing encephalopathy and fatty liver

  • affects children/teens recovering from viral infx (chicken pox)

  • children taking too much aspirin

Labs seen in Reye syndrome: (4)

1. Elevated AST/ALT

2. Increased ammonia

3. prolonged PT d/t liver not making correct amt of blood clotting proteins

4. abnormal electrolytes d/t cerebral edema

What causes CP? (7)

1. drugs

2. kernicterus (severe jaundice)

3. maternal infx (TORCH)

4. premature birth

5. poor O2 to baby

6. traumatic birth

7. meningitis

4 types of CP

1. spastic

2. dyskinetic

3. ataxic

4. mixed

Spastic CP: (4)

1. hypertonic muscles (⬆DTR)

2. abnormal clonus

3. positive Babinski reflex

4. exaggerated reflexes

Dyskinetic CP: (5)

1. involuntary mvmts

2. poor tongue/swallowing mvmts

3. drools

4. speech difficult to understand

5. jerking

**think of parkinson’s tardive dyskinesia

Ataxic CP: (3)

1. poor balance

2. awkward, wide gait

3. cant do fine motor motions

• finger to nose test

• rapid repetitive mvmts

CP physical assessment: (7)

1. anoxia @ birth (lack O2 when born)

2. strabismus (cross eyed)

3. refractive disorders (needs glasses)

4. abnormal speech rhythm/ articulation

5. recurrent seizures

6. ADHD

7. autism

Spina Bifida care: (5)

1. cover defect w/ moist, sterile, non-adhesive dressing (prevent drying)

2. dressing changed q2-4 hrs

3. newborn in PRONE!!

4. dont place diaper over defect (prevent pressure on sac/rupture/infx)

5. LATEX FREE environment

Head Injury assessment: (5)

1. s/s increased ICP

2. laceration/hematoma @ site

3. skull fracture

4. hemotympanum

• blood behind ear drum (use otoscope)

5. periorbital ecchymosis (raccoon eyes)

Early signs of head trauma in infants: (5)

1. bulging fontanel (⬆ICP)

2. sun setting eyes (driven downward bilaterally—usually in hydrocephalus)

3. separation of cranial sutures

4. increased sleep

5. poor feeding

Late signs of head trauma: (4)

1. pupillary changes

2. posturing (Decorticate/Decerebrate)

3. Cheyne-stokes respirations

4. CUSHINGS triad

Define Cushing’s Triad and how does it present: (3)

• LATE sign ⬆ICP

1. HTN (⬆systolic BP + wide pulse pressure)

2. bradycardia

3. Irregular resp

Nurse management for Head Injuries-basic: (9)

1. Cervical collar (DONT flex head)

2. Assess fluid drainage from ears/nose (CSF)

3. Seizure precautions

• pad rails

• nothing in mouth

4. Keep body aligned

5. Minimize suction/cough/blow nose (⬆ICP)

6. Stool softener

7. LOC

8. PERRLA

9. GCS

Basilar skull fracture signs: (2)

Basilar

• base of skull

1. raccoon eyes

2. CSF leak

4 complications of skull fractures

1. epidural hematoma

• causes rapid neuro decline

2. subdural hematoma

• bleed after head injury

  • causes ⬆ICP→ HA, slurred speech

3. cerebral edema

• ⬇blood flow to brain

• ⬆ICP

4. brain herniation

• brain tissue shifts d/t high ICP (life threatening!!)

• Cushings

• loss of blinking & gag reflex

• pupils dont react to light

Infant GI system compared to older kids: (5)

1. smaller stomach capacity→ need frequent feeds

2. low esophageal sphincter tone → increased reflux

3. slower gastric emptying

4. immature liver function→ limited drug metabolism

5. higher fluid needs d/t faster peristalsis

Feeding and digestions in infants: (4)

1. suck/swallow/breathe develops @ 34-36 weeks

2. breastmilk easier to digest then formula

3. immature enzymes (amylase and lipase)

4. introduce solids @ >6 mon.

• look @ changes in stool

• C/D

What physical assessments important in pediatric GI evals?

• hx (2)

• inspection (2)

• auscultation (1)

• palpation (3)

• history:

1. subjective:

• amt of stool/characteristics

• diet/feeding patterns

• if they were sick

• pain

2. objective: growth (h/w)

• hydration status

• inspection

1. distention

2. visible peristalsis

• auscultation

1. hyper/hypo-active bowels

• palpation

1. tenderness

2. mass

3. rigid

GI Red flags in peds that needs immediate evals: (7)

1. bilious vomiting

• means intestinal blockage

2. projectile vomit

• d/t pyloric stenosis

3. failure to thrive

• d/t poverty, SDOH

• multiple kids, fixed income→ dilute formula

• chronic illness (CF)

4. severe dehydration

• sunken fontanels/eyes

• lethargic

5. bloody stools

• intestinal injury

6. absent bowels sounds

• obstruction (mass/poop) → perforation → peritonitis

7. persistent abd pain

• appendicitis

• infx

Common cause/risk factors for dehydration: (5)

1. V/D

2. dont drink fluids

3. viral/bacterial infx

• rotavirus

• salmonella

• e.coli

• c.diff

4. crowded environments (sick→ dehydrated)

5. contaminated water

s/s severe dehydration: (9)

1. sunken fontanels

2. lethargic

3. oliguric + concentrated urine

4. dry mucous membranes

5. < 6-8 wet diapers/day

6. no tears when crying

7. skin turgor > 3 sec

8. pale

9. hypotensive

Nurse care for dehydrated child: (3)

1. oral rehydration: mild 40-50 mL/kg over 4 hrs

• moderate 100mL/kg over 4 hrs

1. no juice/caffeine/soda/jello/broths (salty)

2. draw labs

• CBC

• BUN/Cr

• Urine specific gravity

• stool test (tape test for pinworms)

Pinworm infx (enterobiasis)

• how it spreads (3)

• symptoms (2)

• diagnosis (1)

→ spreads through

• 1) contaminated hands (scratching butt then touching mouth)

• 2) Dirty toys/ surfaces

• 3) Close contact with infected children

→ s/s:

1. itchy butthole

2. restless sleep

→ dx:

1. tape test

• Clear tape pressed against the butthole in the morning before bathing

  • worm eggs stick to tape

What parent education helps prevent GI infx? (6)

1. rotavirus vax

2. shower/ skin care daily

• babies are exception bc they dont get as dirty

3. changes undies daily

4. clip nails (pinworms)

5. no sharing cup/utensils

6. no undercooked/raw meats

GERD s/s in children (5)

1. excessive spitting up

2. projectile vomiting

3. back arching

4. heartburn/ abd pain

5. poor weight gain

Interventions for GERD: (4)

1. upright feeding

2. burping

3. smaller, frequent feeds

4. no caffeine, citrus, spicy, peppermint for older children

Pyloric stenosis s/s: (4)

1. projectile, non-bilious vomit

2. olive shaped mass in RUQ

3. visible peristalsis

4. metabolic alkalosis (vomiting)

Common causes of pediatric constipation: (5)

1. holding stool in

2. transition from cows milk

3. toilet training stress

4. fear of public/school bathrooms

5. painful and doesnt want to go

What is encopresis and s/s: (4)

• repeated involuntary stool leakage bc of chronic constipation

s/s basically same as constipation:

1. low fiber

2. not enough fluids

3. fear of toilet during training

4. fear of public restrooms

tx for encopresis: (3)

1. empty colon w/ laxatives/enemas

2. schedule toilet time after meals (30 mins)

3. gradually reduce bowel meds

s/s of appendicitis: (6)

1. periumbilical pain→ RLQ pain

2. anorexia

3. guarding

4. rebound tenderness

5. pain w/ mvmt (jumping/ coughing)

6. N/V/D/C

signs of perforation: (4)

1. sudden relief of pain, then extreme pain

2. rigid abd

3. high fever

4. toxic appearance

appendicitis physical exams: (4)

1. McBurneys point tenderness: RLQ pain when pressing down

2. rovsings sign: pain in RLQ when left side is pressed

3. psoas sign: pain in right abdomen when right leg lifted

4. obturator sign: pain when hip and knee are bent and the leg is rotated inward

Nursing care for appendicitis: (4)

1. no heat to abdomen

2. no enema or laxatives

3. IVF

4. NPO

Define intussusception:

• include age

• bowel blockage in 3 mon.-6 yrs where part of intestine telescopes into another

s/s of intussusception: (4)

1. knees drawn to chest

2. sausage shaped abdominal mass in RUQ

3. “Dance sign”: bowel shifts out of the RLQ, leaving that area empty due to telescope

4. stools mixed w blood, mucus “jelly stool”

What causes Hirschsprung Disease?

• no ganglion cells in colon → NO peristalsis

Cardinal sign of Hirschsprung disease in newborn?

• FAILURE to pass meconium w/in 24-48 hrs after birth

Symptoms of Hirschsprung disease in infant/children? (5)

1. foul smelling stool

2. ribbon-like or pellet-like poop

3. distention

4. undernourished, anemic appearance

5. palpable fecal mass

Whats the most common cause of UTIs in children?

Escherichia Coli (E.Coli)

UTI risk factors: (11)

1. Vesicoureteral Reflux: pee flows backwards from bladder → ureters/kidneys

2. urinary stasis (holding pee)

3. catheters

4. uncircumcised male (not cleaned well)

5. female (urethra close to rectum)

6. tight/synthetic undies

7. wet bathing suits

8. bubble baths

9. pinworm infx

10. sexual activity (pee after)

11. toilet training stage

What are UTI symptoms in infants? (8)

1. hematuria

2. crying w/ urination

3. jaundice

4. cyanosis

5. V/D

6. irritable/lethargic

7. poor feeding

8. fever/hypothermia

manifestation of pee in UTIs: (4)

1. thick and cloudy w/ mucous

2. pyuria (WBC in urine)

3. bacteria in urine

4. foul odor

UTI symptoms in older children? (5)

1. fever w/ severe flank/abd pain (leukocytosis→ pyelonephritis)

2. hematuria

3. dysuria (malodourous)

4. incontinence in toilet trained child

5. boys dribble when peeing

Nursing actions for UTIs: (3)

1. drink water!

2. frequent peeing + total emptying of bladder

• push on bladder

3. high fiber!! (prevent constipation)

How to collect urine: (3)

1. clean catch method/ or take from catheter

• collect midstream urine

2. collect first morning urine

3. help w/ suprapubic aspiration if needed

UTI parent education: (8)

1. wipe front to back

2. “double voiding”

3. wear cotton/loose undies

4. dont stay in wet clothes

5. NO bubble baths/hot tubs/whirlpools

6. clean foreskin

7. void after sex

8. no caffeine

whats hydronephrosis?

• causes? (2)

• swelling of kidney due to buildup of pee when obstructed

  • Vesicoureteral Reflux

  • kidney stones

whats Nephrotic Syndrome?

• kidneys leak protein into urine (preschoolers 2-3 years old)

  • proteinuria

signs of nephrotic syndrome: (7)

1. edema

• periorbital (face)

• generalized anasarca (abdomen, genitals, legs)

2. weight gain

3. ascites

4. frothy dark urine

5. pallor white lines in nails (Muehrcke)

6. anorexia

7. lethargic/irritable/fatigue

Nursing interventions Nephrotic syndrome: (5)

1. monitor daily weights and urine protein

2. strict I/O

3. skin care

4. LOW Na diet

5. elevate edematous parts (legs)

• complications: clots/circulatory insufficiency

Parent education Nephrotic syndrome: (3)

1. Check loss of protein in urine

2. Low Na diet

3. monitor clotting risk/PE

• anticoagulants lost in urine = ⬆platelets (500,000-1,000,000)

Whats Wilms Tumor?

• most common kidney cancer in children (2-3 y/o)

key nursing precaution for Wilms Tumor: (3)

1. DONT palpate abdomen!! (can rupture it(

2. prep for nephrectomy

3. NO contact sports!!!!