Pediatric Exam 2 Study Guide

Pediatric Anatomy & Physiology (Exam Objective 2.1)

Cardiovascular (Children vs Adults)

  • Smaller Heart Size:

    • Results in higher heart rate (HR) necessary to maintain cardiac output (CO).

  • Stroke Volume Limitations:

    • Cardiac output largely depends on higher heart rate than stroke volume.

  • Immature Myocardium:

    • Less capable of compensating for stressors like increased oxygen demand.

  • Increased Oxygen Consumption:

    • Leads to rapid decompensation when stressed.

Respiratory Anatomy and Physiology

  • Narrower Airways:

    • Results in significant risk of obstruction, which poses serious health issues.

  • Fewer Alveoli:

    • Reduces surface area for gas exchange.

  • Diaphragmatic Breathing:

    • Diaphragmatic or abdominal breathing is considered normal in children.

  • Immature Immune System:

    • Increased vulnerability to infections.

Cardiovascular Disorders

Signs of Decreased Cardiac Output (VERY HIGH YIELD)

  • Tachycardia:

    • Considered the earliest sign of decreased cardiac output.

  • Poor Feeding and Fatigue:

    • May indicate declining heart function.

  • Cool Extremities:

    • Peripheral circulation can be reduced.

  • Delayed Capillary Refill:

    • Cap refill time greater than 3 seconds is concerning.

  • Decreased Urine Output:

    • Reflects renal perfusion issues.

  • Hypotension:

    • This is considered a late sign of severe cardiac output reduction.

Congenital Heart Defects (Know shunting & oxygenation)

Atrial Septal Defect (ASD)

  • Shunting: Left to right.

  • Signs and Symptoms:

    • Generally mild; may be asymptomatic.

    • Fixed split second heart sound (S2).

    • Increased risk for heart failure if defect is large.

Ventricular Septal Defect (VSD)

  • Prevalence: Most common congenital heart defect (CHD).

  • Murmur: Loud holosystolic murmur.

  • Signs and Symptoms:

    • Heart failure symptoms, poor feeding, failure to thrive (FTT).

    • Increased pulmonary blood flow leading to congestion.

Tetralogy of Fallot

  • Shunting: Right to left.

  • Four Defects:

    1. Ventricular septal defect (VSD)

    2. Pulmonary stenosis

    3. Right ventricular (RV) hypertrophy

    4. Overriding aorta

  • Signs and Symptoms:

    • Severe cyanosis; clubbing of fingers.

    • Known as “Tet spells” may require child to assume a knee-chest position for relief.

  • Nursing Interventions:

    • Place child in knee-chest position, administer oxygen, calm the child, morphine if ordered.

Transposition of the Great Vessels

  • Definition: Aorta and pulmonary artery are switched.

  • Consequences: Leads to life-threatening cyanosis; requires mixing of blood (e.g., through PDA, ASD, VSD).

  • Nursing Focus:

    • Administer Prostaglandin E1 to keep the patent ductus arteriosus (PDA) open.

    • Surgical correction is ultimately required.

Patent Ductus Arteriosus (PDA)

  • Murmur: Continuous, machine-like murmur.

  • Vital Signs: Bounding pulses, widened pulse pressure.

Post-Operative Care for Surgical Closure of CHD

  • Monitoring:

    • Respiratory status (monitor for distress).

    • Manage pain effectively.

    • Vigilantly observe for signs of bleeding and infection.

Cardiomegaly & Failure to Thrive (FTT)

  • Causes: Associated with chronic heart failure (HF).

  • Nutritional Needs:

    • High calorie formulas recommended.

    • Encourage small, frequent feeding intervals.

  • Monitoring: Daily weights to track progress.

Cardiac Catheterization – Post-Procedure Care

  • Assessment:

    • Monitor for distal pulses to assess circulation.

    • Keep the catheterized extremity straight.

  • Observe for:

    • Signs of bleeding, vital signs (VS), and cardiac rhythm.

  • Activity Restrictions: Bed rest as per protocol.

Digoxin (HIGH YIELD)

  • When to Hold:

    • Apical pulse < 90-110 bpm for infants; <70 bpm for children.

  • Laboratory Monitoring:

    • Maintain digoxin level within the therapeutic range (0.5-2 ng/mL).

    • Monitor potassium levels (↓ K can increase toxicity).

  • Signs of Toxicity:

    • Bradycardia, nausea/vomiting (N/V), and arrhythmias.

Lasix (Furosemide)

  • Mechanism: Causes potassium loss; thus, watch for hypokalemia.

  • Dietary Recommendations: Encourage potassium-rich foods such as:

    • Bananas

    • Oranges

    • Potatoes

Respiratory Disorders

Respiratory Distress Signs and Symptoms (PRIORITY)

  • Tachypnea: Rapid breathing.

  • Nasal Flaring: Indicator of respiratory distress.

  • Retractions: Intercostal or substernal pulling.

  • Grunting: Associated with effortful breathing.

  • Cyanosis: Indicating hypoxemia.

  • Decreased Level of Consciousness (LOC): This is considered a late sign of severe distress.

Croup (Laryngotracheobronchitis)

  • Key Characteristics:

    • Barking cough symptom and inspiratory stridor.

    • Symptoms tend to worsen at night.

  • Dos & Don’ts:

    • DO:

    • Provide cool mist, keep child calm, maintain an upright position.

    • DO NOT:

    • Inspect throat or agitate the child.

Epiglottitis (EMERGENCY)

  • Key Symptoms:

    • Drooling, severe dysphagia, tripod position, high fever.

  • Nursing Actions:

    • Avoid examining the throat to prevent airway spasm, prepare for airway management, administer IV antibiotics.

RSV (Bronchiolitis)

  • Symptoms:

    • Wheezing, crackles, apnea in infants.

  • Nursing Actions:

    • Suction before feeding, oxygen therapy, ensure hydration, apply contact precautions.

Asthma

Early Symptoms

  • Cough primarily at night, wheezing, chest tightness.

  • Interventions:

    • Short-acting bronchodilators (e.g., albuterol) for immediate relief.

    • Corticosteroids for inflammation control.

    • Monitor peak flow rates for managing asthma attacks.

Renal & Urinary Disorders

Normal Urine Output

  • Infants: 1-2 mL/kg/hr.

  • Children: ≥ 1 mL/kg/hr.

  • Adolescents: ≥ 0.5 mL/kg/hr.

Acute Glomerulonephritis (Post-Streptococcal)

  • Key Features:

    • Cola-colored urine, periorbital edema, hypertension (HTN).

  • Nursing Management:

    • Monitor blood pressure, restrict fluid intake, keep track of intake and output (I&O), and perform daily weights.

Nephrotic Syndrome (VERY HIGH YIELD)

  • Signs and Symptoms:

    • Massive proteinuria, hypoalbuminemia, generalized edema, significant weight gain, decreased urine output.

  • Nursing Interventions:

    • Monitor urine output, daily weights, focus on infection prevention, and corticosteroid administration.

Urinary Tract Infection (UTI) and Urinalysis

  • Urinalysis Results:

    • Cloudy urine, presence of leukocytes, and nitrites; febrile infants may present without any clear source.

Chronic Kidney Disease

  • Key Features: Metabolic acidosis on arterial blood gas (ABG), electrolyte imbalances, and growth failure.

Renal Failure Complications

  • Complications:

    • Hyperkalemia, fluid overload, metabolic acidosis, and hypertension.

GI Disorders

Short Bowel Syndrome

  • Symptoms: Malabsorption, diarrhea, weight loss.

  • Nursing Management: Nutritional support, electrolyte monitoring, potential requirement for total parenteral nutrition (TPN).

Mechanical Intestinal Obstruction

  • Key Symptoms: Abdominal distention, vomiting, absent bowel sounds.

Acute Appendicitis

  • Key Indicators:

    • Right lower quadrant pain, rebound tenderness, fever.

  • Nursing Actions:

    • Maintain NPO status, avoid enemas/laxatives, administer preoperative antibiotics.

Cleft Lip/Palate

  • Feeding Difficulties: Increased risk for aspiration.

  • Post-Operative Care:

    • Position patient supine or side-lying, avoid straws, use a syringe or special feeder.

Infectious & Immune Disorders

Streptococcal Pharyngitis

  • Symptoms: Fever, sore throat, strawberry tongue appearance.

  • Treatment: Full course antibiotic therapy is mandatory.

Rheumatic Fever

  • Characteristics: Develops after untreated streptococcal infections, manifesting as migratory joint pain and carditis.

Otitis Media

  • Signs: Ear pulling, fever, irritability.

Fluids, Safety & Emergencies

Fluid Bolus – Identifying Signs of Improvement

  • Indicators:

    • Improved blood pressure, improved capillary refill time, increased urine output, enhanced mental status.

Post-Operative Pediatric Care

  • Responsibilities:

    • Airway management takes priority, effective pain control, regular vital sign monitoring, and infection prevention measures.

Sudden Infant Death Syndrome (SIDS) Prevention

  • Recommendations: Position infants on their backs to sleep, use a firm mattress without loose bedding, room share without bed-sharing.

Tumor Precautions

  • Precautions: Implement neutropenic protocols, infection prevention strategies, and avoid fresh flowers or raw foods.

Psychosocial & Family Teaching (Objectives 2.5–2.7)

  • Common Parental Concerns: Fear of loss of control over the child’s care.

  • Encouragement: Engage parents in their child’s care, fostering active participation.

  • Communication Strategies: Utilize therapeutic communication techniques including:

    • Open-ended questions, active listening, and developmentally suitable teaching.

ATI EXAM TIPS

  • Follow the ABCs: Airway → Breathing → Circulation.

  • Understand that cyanotic defects represent right-to-left shunts.

  • Recognize that edema along with proteinuria indicates nephrotic syndrome.

  • Remember that tachycardia is an early distress signal.

  • In cases of epiglottitis, do NOT visualize the throat to prevent exacerbation of conditions.