Peds Exam 3

Medication Administration and Dosing Guidelines

  • Mixing Medications:

    • Do not mix medications with anything, especially when administering to ensure proper dosing is achieved.

  • Handling Vomiting:

    • If a dose is vomited, do not give an extra dose immediately. Wait until the next scheduled dosing interval to provide the normal dose to avoid overdose as absorption is uncertain.

  • Missed Doses:

    • If a patient misses two doses or 24 hours of dosing, contact the physician immediately.

    • If a dose is forgotten within an hour, it's typically acceptable to administer it. However, if over two hours have passed, do not administer the dose and wait for the next scheduled time.

  • Education for Parents:

    • Teach parents to set reminders (like alarms) for medication timings to ensure consistent dosing.

Toxicity Signs and Symptoms

  • Recognizing Toxicity:

    • Signs of toxicity include yellow halos and cyanosis.

    • In infants, non-verbal cue symptoms may present as vomiting or irregular pulse.

  • Monitoring Symptoms:

    • In cases of suspected toxicity, inform the primary care provider.

Relationship Between Diuretics and Potassium

  • Understanding the Importance:

    • Diuretics decrease potassium levels (hypokalemia), which increases the risk of digitoxicity (toxicity of digoxin).

    • Monitoring potassium levels in patients on diuretics and digoxin is crucial.

  • Monitoring in Patients:

    • Always assess digoxin levels and watch for symptoms of toxicity in potassium-depleted patients.

Medication Storage and Measurement

  • Storage Guidelines:

    • Medications should be stored in a locked cabinet to prevent accidental ingestion, particularly in pediatrics.

  • Accurate Measurements:

    • Stress the importance of precise dosing; improper dosing can be lethal.

    • Normal digoxin doses are often less than 1 ml. For instance, doses of 4, 5, or 6 ml are incorrect.

Growth and Dosing Reevaluation

  • Growth Spurts Impact on Dosage:

    • Pediatric patients undergoing growth spurts must have their medication dosages reevaluated regularly as their weight and height significantly influence dosing needs.

Feeding Guidelines for Cardiac Patients

  • Feeding Challenges:

    • Children with heart failure may struggle with feeding due to respiratory distress.

    • Parents should provide smaller, more frequent feedings rather than large quantities to avoid tiring the child.

    • Holding infants upright during feeding can minimize the risk of GERD (gastroesophageal reflux disease).

  • Assessment:

    • If an infant cannot consume sufficient nourishment in a 30-minute feeding window, recommend switching to an NG (nasogastric) tube for feeding.

  • Monitoring for Fatigue:

    • Signs of exhaustion during feeding include tachypnea and diaphoresis (sweating).

  • Nutritional Support:

    • Consider using concentrated formulas to increase caloric intake without increasing the work of breathing.

Intervention Strategies for Cardiac Patients

  • Monitoring Symptoms and Needs:

    • Observe peripheral perfusion and assess apical heart rates before administering digoxin.

    • For infants: If heart rate < 90, do not administer.

    • For children: Less than 70 is too low for digoxin administration.

  • Reducing Cardiac Workload:

    • Limit feeding times and incorporate rest periods. If children appear fatigued, discontinue feeding promptly.

    • Encourage activities that are self-limiting to allow children to stop when they feel tired.

    • Physiological responses to crying or anxiety may necessitate preemptive oxygen administration during stressful procedures.

Congenital Heart Defects Overview

  • Classification of Congenital Heart Defects:

    • The American Heart Association identifies 26 cardiac defects, commonly categorized as left-to-right shunts, stenosis, or right-to-left shunts.

  • Left-to-Right Shunt Examples:

    • Patent ductus arteriosus (PDA), atrial septal defect (ASD), ventricular septal defect (VSD).

    • This involves shunted blood flow from the left side of the heart back to the right, increasing pulmonary blood flow and pressure.

  • Stenotic Lesions:

    • Conditions such as pulmonary stenosis and aortic stenosis, which are characterized by narrowing of vessels impeding flow.

  • Cyanotic Lesions:

    • This includes defects like Tetralogy of Fallot, characterized by decreased pulmonary blood flow leading to systemic hypoxia (cyanosis).

Tetralogy of Fallot Symptoms and Management

  • Defects Involved in Tetralogy of Fallot:

    • Pulmonary stenosis, right ventricular hypertrophy, overriding aorta, and VSD.

    • This condition leads to significant oxygen deficits and chronic cyanosis.

  • Symptoms of Tetralogy of Fallot:

    • Patients might exhibit symptoms of hypoxia and should be monitored for changes in baseline color.

    • They generally endure multiple staged surgeries for correction due to the complexity of their condition.

Coarctation of the Aorta

  • Critical Heart Defect:

    • Coarctation manifests as a narrowing of the aorta, leading to different blood pressures in the upper and lower extremities.

    • It results in poor circulation to the lower body while the upper body remains well-perfused.

  • Intervention Strategy:

    • Prostaglandin E infusion is used to maintain patency of ductal flow until surgical intervention can be performed.

  • Clinical Testing:

    • Blood pressure assessments in all four limbs are vital in diagnosing coarctation.

Endocarditis

  • Definition and Risks:

    • Endocarditis is a bacterial infection affecting the inner lining of the heart, potentially damaging the heart valves.

    • Associated with long-term presence of central lines.

  • Signs and Symptoms:

    • Low-grade fever, new or changed heart murmur, splenomegaly, and the presence of Osler’s nodes or Janeway lesions serve as indicators of endocarditis.

  • Prophylactic Measures:

    • Children with congenital defects are at high risk and may require antibiotic prophylaxis prior to dental procedures.

Rheumatic Fever and Heart Disease

  • Cause of Rheumatic Fever:

    • Provoked by untreated streptococcal infections, leading to joint, heart, and skin symptoms.

    • Rheumatic fever can escalate to rheumatic heart disease, characterized by valvular damage.

  • Diagnosis Criteria:

    • Requires documentation of three out of five symptoms such as migratory polyarthritis, carditis, chorea, erythema marginatum, and subcutaneous nodules.

  • Management:

    • Treatment of the underlying streptococcal infection with antibiotics; those with significant valvular damage often require long-term prophylaxis.

Kawasaki Disease

  • Definition and Phases:

    • Kawasaki disease is a self-limiting vasculitis, primarily affecting young children, characterized by prolonged fever and risk for coronary artery aneurysms.

  • Symptoms:

    • High fever unresponsive to usual antipyretics, conjunctivitis without discharge, strawberry tongue, rash, skin peeling on extremities, and extreme irritability.

  • Treatment Protocol:

    • Administer IV gamma globulin and aspirin; monitor closely for symptoms and long-term follow-up due to risk of aneurysms.

Hypertension Management in Pediatrics

  • Emerging Concern:

    • Increasing prevalence of hypertension in children necessitates early detection and management strategies.

  • Lifestyle Interventions:

    • Family-wide dietary changes, sodium reduction, and exercise are essential in reversion strategies for childhood hypertension.

  • Pharmacologic Considerations:

    • Medications should be reserved for cases where lifestyle changes are ineffective due to potential adverse effects; careful monitoring is essential with medication administration.