PEDS Ch. 34 (exam 2)

what to know about (communicate an attitude of calm confidence.)

• Speak quietly & calmly to the child & parents, and remain firm in charge.

• Create a communication plan w/ parent that specifies when they should be called if they’re away from the department (list phone numbers where they can be reach)

• Acknowledge & address the child’s & family’s fears

What to know about (establishing a trusting relationship w/ the child & family.)

• Check back w/ the family often & provide periodic updates if the child and family is separated

• use simple, nonmedical terms.

• Provide comfort measures

• make eye contact w/ the child & family when speaking to them, call the child by name.

• protect privacy direct them to a public telephone, cafeteria, provide space where they can talk quietly.

what to know about (tell the truth)

keep the child informed of what will occur by describing sensations

be honest as possible, if the procedure is painful tell them.

what know about (provide incentives and rewards)

• children 3-12years of age appreciate verbal praise & concrete rewards for good behavior (stickers, fancy bandages, inexpensive toys)

• adults: appreciate being thanked for their patience & their assistance in their child’s care.

what to know about (assess the child’s unspoken thoughts & feelings)

• try to determine what the child is thinking or feeling but not verbalizing

• encourage the child to express thoughts & feelings

infants

• stress increases metabolic demands in infants, offer rest periods during procedures to maintain normothermia

• older infants (9-18months) can exhibit signs of separation and stranger anxiety

• allow parent to hold infant as much as possible

toddler

• do not respond well to restrictions & tend to push any limits imposed.

• may have to restrain, remove any restriction or restrictions as soon as safety permits

• have little understanding of time, procedures should be introduced just before they are initiated.

preschoolers

• avoid using “stick” or “cut” to prevent literal misinterpretations of meanings

• tend to blame themselves for illnesses/injuries (cause and effect believers)

• do not ask parent to restrain the child may be confusing to child & difficult for parent

• more willing to separate, but keep it brief as possible

school age child

Able to understand cause of illness/injury, much less likely to fantasize and exaggerate.

Can understand simple explanation of procedures & able to make decisions of their own care

Help them use coping techniques that work for them due to risk taking behavior starting at this age.

adolescent

• Coping w/ extraordinary changes in their physical appearance

• often concerned with whether they are “normal” and whether others have similar thoughts and feelings

• consider themselves invincible, and many experience overwhelming emotions when a friend dies unexpectedly

• teenagers might either exaggerate or underplay the seriousness of a condition

parents of fear and anxiety may have

their child might die (often the underlying cause of parents’ anger toward healthcare providers)

their child might experience pain (difficult for parents to understand and accept)

their child’s body may be permanently altered (children will have permanent scars or body changes)

parental guilt

feel responsible for their child’s illness/injury

they are submitting their child to a painful experience

they lack the knowledge to make educated decisions

What questions to ask for respiratory rate & effort (initial observations for triage)

• breathing rapid or shallow?

  • using accessory muscles?

what to observe & assess for kids in respiratory rate and effort

abnormal breath sounds and assess oxygen saturation by pulse oximeter

slow respiratory rate

(child breathing at normal rate for an adult)

signs of respiratory distress in a child

nasal flaring, head bobbing, grunting, stridor, upright position, and prolonged expirations

accessory muscles used dury respiratory distress

substernal, intercostal, or subclavicular retraction

what to look for in skin color for initial observations for triage

skin is pale, mottled, cyanotic

abnormal skin color could be result of

respiratory distress or failure and inadequate tissue perfusion (shock)

response to the environment

is the child alert, interactive, crying, sleeping, or limp

responsiveness is important w/ preverbal kids

breathing assessment

level of consciousness, rate and depth of breathing, breath sounds, and the child’s respiratory effort are indicative of relative oxygenation.

RR should never exceed 60 per min

Cardiovascular assess

cap refill, observing child;s skin color & temp, assess central and peripheral pulse rate & quality.

Can compensate more effectively for fluid loss (increase HR & peripheral vasoconstriction)

late sign of shock in a child

hypotension due to fluid loss, compensatory mechanism no longer maintaining cardiac output

rapid neurologic assessment consist of

• pupillary reactivity & size

• brief mental status assessment - (AVPU: Alert, responds to voice, responds to pain, unresponsive)

• GCS (Glasgow Coma Scale)

kids have larger body surface area to weight ratio makes them as risk for (exposure, primary assessment)

hypoerthermia

what risk is higher in neonates in exposure (primary assessment)

hypoxia and hypoglycemia from the use of brown fat for nonshivering thermogenesis

ways how to maintain normothermic state

overhead warmers/ heat lamps

warmed IV fluids

humidified oxygen

removal of wet clothes & providing warm blankets

vitals to start with first (secondary assessment)

respiratory rate & pulse/HR

vitals to get last because they can be more upsetting (secondary assessment)

temperature and blood pressure

How to obtain a history

SAMPLE:

Signs & symptoms

Allergies

Medications

Prior illness/injury

Last meal & eating habits

Events surrounding the injury or illness

Head to toe assessment

document any findings that might affect the child’s condition

inspect all body surfaces look for fractures, lacerations, contusions, penetrating injuries.

observe skin for petechiae, purpura or rashes.

orogastric tubes should place

in kids with suspected head trauma because of the risk of misplacement and injury with a nasgastric tube in kids with basilar skulls and facial fractures.

gastric tubes are places to reduced

gastric inflation that can place pressure on the diaphragm and decrease ventilation effectiveness (kids are diaphragmatic breathers)

another way to determine a kids weight and medication dosages

length based resuscitation tape (Broselow tape)

indicates: fluid bolus vols, defib energy lvls, size of peds airway BV mask vent, laryngoscope, endo tube, gastric tube, urinary cath, chest tubes, IV cath.

use in caution w/ overweight kids.

most common causes of cardio pulmon. arrest in kids

shock and respiratory failure

asphyxiation (infants) and kids

Circulation for CPR for kids

CAB (circulation, airway, breathing)

ventilations should be given at a rate

12 to 20 per min or 1 breath every 3 to 5 seconds; each breath should be given over 1 second.

repositioning the head and placing __ under the child’s shoulders can facilitate?

Rolled up towel & improved air exchange

Large number of aspirations attributed to

coins, small toy parts, and certain foods (candy, nuts, grapes)

children older than 1 year AHA recommends

heimlich maneuver

__ initiated for all unresponsive infants & kids w/ a foreign body aspiration

CPR

removal of a foreign object in an infants involves

place infant in downward slant and give 5 back blows w/ five chest compressions

obstruction continues after these maneuvers they use what

direct laryngoscopy and use of Magil forceps to remove the foreign body

Tracheostomy is LAST RESORT

drug of choice for management of cardiac arrest, arrhythmias, and hemodynamic instability

epinephrine

shock is what

is a series of acute and complex problems that result in an increase in oxygen demand but a decrease in oxygen supply.

causes of shock

dehydration, blood loss, infection, allergic reactions, and cardiac problems

hypovolemic shock

most common cause of shock

decrease in circulating blood or fluid volume

causes of this: decrease in circulating blood or fluid volume, hemorrhage, burns, and dehydration.

blood loss can be caused by

trauma or surgery, fluid and plasma losses that occur w/ vomiting and diarrhea, burns, and diabetic ketoacidosis

Distributive (spetic) shock

abnormality in distribution of blood flow or inability of the body to maintain vascular tone through vasoconstriction

results in: abnormal vasodilation & decreased system vascular resistance

causes of distributive shock

anaphylaxis, CNS or spinal injury, and drug intoxication

septic shock

is a combination of distributive, hypovolemic, and cardiogenic shock

occurs when microbial toxins(bacteria, viruses, fungi, rickettsiae) are in the blood

microbial toxins cause what in septic shock

cascade of metabolic, hemodynamic, and clinical changes, resulting in impaired organ perfusion and hypotension

organisms responsible for septic shock

Streptococcus pneumoniae, Staphylococcus aureus, Neisseria meningitides

• group A Streptococcus in infants and children

who is at greater risk for septic shock

infants & kids w/ debilitating illnesses, prolonged hospitalizations in ICU w/ many invasive lines and those who are immunosuppressed

Manifestations of hypovolemic shock

Dry mucous membranes

• Depressed fontanel

• Cold, clammy skin

• Oliguria

• Poor skin turgor

• Delayed capillary refill

manifestations of distributive shock: vasodilation

extremities that are warm to the touch

tachycardia, tachypnea

manifestations septic shock

rapid, thready pulse

cyanosis

cold, clammy skin

purpuric skin lesions

narrow pulse pressure

oliguria or anuria

manifestations of cardiogenic shock

hepatomegaly

cardiomegaly

increased central venous pressure

periorbital edema

crackles

diaphoresis

reduced cap refil

differences in proximal and distal pulses

treatment for hypovolemic shock

IV crystalloid infusion of NS or Lactated Ringer’s solution

• caused by hemorrhage: transfusions may be considered

  • Colloids (albumin, blood products)

  • used after inital treatment w/ crystalloids

treatment for distributive shock

restore hemodynamic w/ fluid resuscitation

• steroids, medication to treat hypoglycemia & electrolyte imbalances

-admin of blood products may be required to combat complications of distributive shock.

septic shock treatment

Parenteral antibiotics

Vasoconstrictors can be used to increase vascular tone

Inotropic medications and vasodilators are used to manage the cardiovascular instability

Cardiogenic Shock

Dobutamine and milrinone are the initial drugs of choice for treating cardiogenic shock.

Invasive monitoring of central venous pressure, arterial blood pressure, and pulmonary artery pressure helps to identify hemodynamic changes

what is a late sign of shock

hypotension

kids can compensate for a 25% blood loss

what is the lower limit of systolic bp for infant younger than 1 month

60 mm hg

lower limits vor systolic bp in infants 1-12 months

70 mm hg

lower limits for systolic bp for kids older than 1 year

70 + 2x the kid’s age in year mm Hg

clinical manifestations of hypovolemic shock

dry mucous membranes

depressed fontanel

cold clammy skin

oliguria

poor skin tugor

delayed cap refill

early signs of septic shock

vasodilation

extremities are warm to the touch

tachypnea

tachycardia

late signs of septic shock

rapid thready pulse

cyanosis

cold clammy skin

purpuric skin lesions

narrow pulse pressure

oliguria or anuria

clinical manifestations of cardiogenic shock

Hepatomegaly or cardiomegaly

increased central venous pressure

Periorbital edema

Crackles

Diaphoresis

Oliguria

Reduced capillary refill

Differences in proximal and distal pulses

blunt trauma

blunt trauma is often result of motor vehical crash or pedestrian vs car

motor vehical trauma

related to child NOT in a car seat.

pedestrian vs car results in Waddell’s triad.

mutiple trauma

injuries to more than one body system

Human bites.

prophylactic antibiotics may be prescribed due to increase risk of infection