PEDS EXAM 2 STUDY GUIDE
Development
Erikson stages:
o TRUST vs MISTRUST (birth to 1 year old) Infant. No concept of danger. Falls. Inhalation
of foreign objects-everything goes in the mouth. They cry to relay their needs- you can’t
spoil them.
o AUTONOMY vs SHAME AND DOUBT (1 to 3 years old): Toddler. “Negativism”persistent negative responses to questions. “Ritualization” provides sense of comfort.
Need to maintain sameness. REGRESSION. Not aware of dangers
o INITIATIVE vs GUILT (3 to 6 years old): Preschooler. Feelings of guilt, anxiety, and fear
may result from thoughts that differ from expected behaviors. Believe in the power of
words and are very literal. “magical thinkers”-egocentric. Animism- they think inanimate
objects are alive.
o INDUSTRY vs INFERIORITY (6 to 12 years old): School age. Like to have a sense of
accomplishment, carry tasks through to completion. Children learn to compete and
cooperate with others, and they learn the rules! Form groups (same sex groups) Feelings
of inferiority is developed if too much is expected of them or if they believe that they
cannot measure up to the standards set.
o IDENTITY vs ROLE CONFUSION (12 to 18 years old): Adolescent. They struggle to fit the
roles they have played and those they hope to play with the current roles adopted by
peers and therefore may result in a role confusion. Peer pressure and approval! Need
for independence and freedom, risk takers.
Types of play and which age groups utilize each type most often:
o Parallel: Toddler. Children play independently but among other children. (side by side
no interaction)
o Associative: Preschooler. Children play together and are engaged in similar or even
identical activity, but there is no organization, division of labor, leadership assignment,
or mutual goals. Children borrow and lend play materials. Each child acts according to
his or her own wishes, there is no group goal.
o Cooperative: School age. There’s RULES. Like to play with SAME SEX. Organized and
children play in a group with other children. They discuss and plan activities for the
purposes of accomplish an end.
Play helps them grow intellectually, socially, sensor motor and to be creative! It puts them in
control and allows them to relay their needs/feelings/frustration. Don’t orient them to
reality. Playing make believe helps them communicate with others.
Communication
o Infants: listening to their cry, talk in low quiet voice. Empower parents to help
o Preschooler: let them touch, feel it, and smell things. Ask specific questions. (yes/no).
Use words they will recognize. (tell time with things they understand-after lunch/nap)
They’re egocentric and “magical thinkers” and believe in animism.
o School age: explanation and reason for everything, simple terms, can’t get them to
communicate, involve them in play!
o Teenagers: Let them express their feeling. Ask open ended questions and be honest
with them
Assessment order of infant and toddler: do heart and lung first if they’re quiet. Don’t take them
away from parent. Belly reader for babies. Pick up baby if they’re crying!
Choking hazards in preschoolers: prevent it by teaching parents common things they choke on.
Preop teaching for preschool and school age: let them touch, feel, smell, hear it
How do you help a young child understand the concept of time or what time it is? Associate it
with things they know. After lunch/nap
Who is most concerned with body image? Teenagers
Relationship of teenagers to risky behaviors- think it’ll never happen to them and engage in
risky behaviors
Best way to get a toddler to eat in a hospital: bring their utensils from home (paw patrol plate),
give them their fav foods, stick with their rituals
The type of injuries is most associated with what factor: developmental age of the child
Atraumatic care: therapeutic care that eliminates or minimizes psychologic or physical distress
by children or their families. Goal is FIRST DO NO HARM! Transitional object- demonstrate on
animal first.
Activities of a 6-month-old:
o hold objects
o rolls around
o starting to teeth
o Separation anxiety starts
o Can hold their head up on their own- don’t need support
Regression in a toddler: Peeing the bed, wanting a bottle, baby talk, holding bowel movement
PERFUSION
General congenital heart disease (CHD):
Assessment: H&P exam- positive prenatal hx (maternal chronic health conditions, DM & Lupus
both have increased incidence of children with CHD), maternal med use- some are teratogenic,
maternal exposure to infection-rubella, family hx of heart defect (parent, sibling)
Inspection: Failure to thrive or poor weight gain!!
Presence of heart murmur is often 1st indicator of heart defect!!! (listen to heart for 1 minute)
Pre-op lab findings in cyanotic heart:
 Polycythemia (chronic low O2, there’s an increase in RBC, trying to get more oxygen.
Blood becomes more viscous and increases risk for clotting!)
 Clubbing (later sign)
How does CHD affect play: children need to play and be around other kids! Will usually limit
themselves/self-regulate
Early signs of impending heart failure:
o Tachypnea
o Tachycardia
o activity intolerance (especially with feeds)
o sweating especially of head
o weight gain-weigh every day!
o Call doc!
o Higher risk for URI bc of fluid accumulation in lungs!
CHF and cardiac defects: HF is a complication common to all severe cardiac defects!
Feeding an infant with CHF:
o more frequent feeds
o feed at 1st sign of hunger
o increase formula density
o GAVAGE feeds- limit nipple feeds to no longer than 30 mins
Discharge teaching for parents after cardiac surgery: Instruct parent to notify physician iftemperature above 37.7 (100 F), new/frequent coughing, turning blue or bluer than normal,
difficulty feeding! Report if they can’t pee
Where to check BP for a child with CHD: ALL 4 extremities
Cardiac catherization: use femoral vein- right side of the heart. Femoral artery- left side of heart
Pre op:
 Teaching parents and age appropriate for child
 Accurate height and weight
 Assess for history of allergies (esp dye/shellfish) in parents -DOESN’T CANCEL TEST!
 History of infection (esp fever or diaper rash in femoral access!)- WILL CANCEL TEST!
 Baseline vitals and pulses- Mark the pedal pulses prior and establishes a baseline
 Baseline labs for renal functions
 NPO status
 Pre med- sedation or antibiotic
Post op:
 Monitor pulses- esp distal to site, note extremity color and temp
 Monitor vitals (dysrhythmias are most common complication)
 Assess dressing- bleeding or hematoma ***if bleeding occurs- apply direct continuous
pressure about 1 inch ABOVE insertion site to localize pressure over the vessel
puncture. For child- CALL right away if they have bleeding!
 Observe for signs of infection- swelling, drainage, bleeding, fever. Notify physician if this
happens!
 Tell child to keep their leg still !!!
Weighing the child with CHD: weigh every day at the same time with same clothing
Timing of digoxin dosing: teach how to draw it up (small amounts), give at same time every day,
if child vomits -call prescriber! Dose depends on WEIGHT!
Signs of digoxin toxicity: seeing halos, nausea and vomiting. FOR INFANT: VOMITING can
indicate toxicity!! Call doc if they vomit, don’t repeat dose!
A fall in the serum potassium level enhances the effects of digitalis, increasing the risk of
digoxin toxicity. Increased serum potassium levels diminish digoxin's effect. Therefore, serum
potassium levels must be carefully monitored
Goals of management: can’t reverse damage if already done.
 improve cardiac function (DIGOXIN- check pulse for a minute before giving. Digoxin
slows the HR! HOLD IF HF is LESS than 60!)
 remove accumulated fluid and sodium: give diuretics- lasix, fluid restriction and low
sodium intake
 decrease cardiac demand: limit physical activity
 Improve tissue oxygenation & decrease oxygen consumption
Predisposition of CHD:
 mother exposure to rubella in first 7 weeks of pregnancy
 family hx of heart defects
 maternal hx of diabetes and lupus
Parental overprotection: Avoid smother love! Children need to play, parents need to
understand this. Giving inconsistent discipline (spoiling them)
Tetralogy of Fallot (TOF):
Pathophysiological changes notes in TOF: An overriding aorta is a congenital heart defect where
the aorta is positioned directly over a ventricular septal defect, instead of over the left
ventricle. The result is that the aorta receives some blood from the right ventricle, which
reduces the amount of o2 in the blood
o has FOUR defects:
o
o
o
o
Ventricular Septal Defect (VSD)
Pulmonary stenosis (PS)
overriding aorta
right ventricular hypertrophy
 They’re severely cyanotic from birth!
 Has right to left shunting! (the right side has increased pressure!) dec
pulmonary pressure
Positioning for TOF to relieve dyspnea: SQUAT (knee-chest position) decreases blood flow to
lower extremities and allows more to upper body (think about them being cyanotic-very blue!)
teach parent to put infant in knee chest position
Problems associated with TOF:
 TET SPELLS- occur with crying or feeding (they become hyper cyanotic/veryyy blue!)
 They’re more at-risk neurological complications (CVA, stroke, brain abscesses and
developmental delay)
COA: (Coarctation of the Aorta)
Taking blood pressures and checking pulses in a patient with COA:
 Take BP in all 4 extremities!
 Will have high blood pressure & bounding pulses in arms/upper extremities
 Low blood pressure in lower extremities. Weak femoral pulses & cool lower extremities
ASD/VSD:
Pulmonary blood flow with VSD: increased pulmonary blood flow. Left to right shunt!
Post cardiac catherization care- same as above
Kawasaki Disease (KD):
Acute- happens all of a sudden. Lasts a long time! No diagnostics
Discharge teaching for KD: importance of follow up care, defer any live immunizations for 11
months after IgG administration, no varicella vaccine. They will be on ASA therapy!
Signs and symptoms of KD:
 strawberry tongue
 fever (doesn’t come down or respond to anything, no Tylenol/antibiotics!)
 CONJUNCTIVA will be red but NO discharge/exudate
 Soles of hands and feet are red and skin is peeling
 lips red
 irritability
Cardiac complication of KD: long term complications of KD include the development of coronary
artery aneurysms disrupting blood flow.
Treatment:
 High dose IgG (effective in reducing coronary artery aneurysm)---repeat if fever
persists
 Aspirin for its antiplatelet effect (risk for reyes syndrome!). initially given for antiinflammatory effect
Don’t want them to get any live vaccine (NO varicella!)
Hemophilia:
LIFELONG disease. They miss one clotting factor (factor 8) and bleed and bleed. Its hereditary,
will not grow out of it!
X linked RECESSIVE TRAIT- males are affected, females may be carriers
Hemophilia treatment and nursing interventions:
o prevent bleeding- close supervision & safe environment for toddlers
o Symptoms may not occur until 6 months of age: WHY?-----Mobility leads to injuries
from falls and accidents (need safe environment for toddlers)
o dental procedures in controlled situation (soft toothbrush -wet it first)
o wear ID bracelet
o shave only with electric razor
o avoid IM injections
o avoid ASA/Ibuprofen- give acetaminophen for mild pain
o superficial bleed- apply pressure for at least 15 mins, ice to constrict. RICE!
o Replace clotting factors (via IV) on a regular basis
o transfusions done at HOME!
o ****Bleeding in the neck, mouth, or thorax is serious because the airway can become
obstructed
o Hemoarthritis---immobilize, elevate and ice—RICE (rest, ice, compression, elevate)
during bleeding episodes. No physical therapy in initial phase; only AFTER! ROM
exercises AFTER bleeding stops to prevent contractures,
Sports activity and hemophilia: NON-CONTACT SPORTS! (chess, golf, bowling, swimming,
fishing)
Use of VIII in hemophilia- hemophilia A affects the most people. They have a deficiency of
factor VIII. Need to replace it via IV. Treatment of bleed: will start transfusing at HOME!!! HIV is
not a concern as much anymore bc the blood is tested better
CELLULAR REGULATION:
Leukemia:
Leukemia is an unrestricted proliferation of IMMATURE WBCs in the blood-forming tissues of
the body!
Acute Lymphoblastic leukemia (ALL)- aka stem or blast cell. Most curable.
Clinical manifestations of leukemia: WBC will be low---not functioning! These abnormal cells
compete for metabolic elements and causes gradual weakening of bone & possible fractures.
Watch for anemia (low RBC), infection(low WBC), and bleeding (low platelets).
Treatment:
o chemotherapy
o HSCT (hematopoietic stem cell transplantation) for ALL (acute lymphoblastic leukemia).
Transplant given when child is in remission
Side effects and complications:
o anemia from decreased RBCs
o infection from neutropenia
o bleeding from decreased platelet production
o can infiltrate other organs too. Spleen, liver, & lymph glands become infiltrated and
enlarged- eventually become fibrotic. CNS becomes infiltrated- IICP
Nursing management:
 Prepare child and family. Multiple painful tests/procedures (explanation/therapeutic
play, sedation)
 Relieve pain
 Prevention of complications of myelosuppression- infection, hemorrhage, anemia
 Manage problems of drug toxicityo N/V- antiemetic, steroids- given BEFORE chemo. Prevents s/s
o anorexia- may need TPN
o mucosal ulceration – bland diet, soft tooth brushes
o neuropathy
o hemorrhagic cystitis- fluids
o ALOPECIA!!!
 Handle chemo with care
Blood transfusions: may be necessary- could have a reaction to blood transfusion!! STOP blood
transfusion and stay with pt if they have a reaction. Don’t force saline after stopping infusion!
SCD (sickle cell disease)
Genetic transmission of SCD: GENETICS (both parents need to have the trait)
Symptoms of vaso-occlusive crisis: severe pain!
Treatment of a vaso-occlusive crisis: hydration, pain med: narcotics such as morphine are given
around the clock! HEAT to sight!
Home management/education:
 first thing is to hydrate them (oral & IV therapy)
 Prevent infection- hand hygiene
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Give penicillin as order for infection
Oxygen- sickled cells don’t carry oxygen good enough
Analgesia for severe pain from vasoocclusion (give MORPHINE! Usually given around the
clock!)
Blood replacements to treat anemia & to reduce the viscosity of the sickled blood
Antibiotics to treat any existing infection
Explanation of the disease & its consequences
Seek early intervention for problems such as fever
IMMUNITY
Primary immunizations are started at BIRTH!- hep B
General side effects of vaccinations
 Within 24-48 hours: local tenderness, erythema, and swelling, and induration at the
injection site
 Low fever, drowsiness, fretfulness, eating less, prolonged or unusual cry
 Low grade fever means they are developing an immune response
 Should see PCP if symptoms severe
Contraindications: severe febrile illness, LIVE VIRUS is not administer to anyone with an altered
immune system. Avoid MMR if allergic to neomycin, streptomycin or eggs
HIB vaccine- provides protection against BACTERIAL MENINGITIS, epiglottis, bacterial
pneumonia, septic arthritis, and sepsis
Schedule for Hepatitis B: starts at birth. Given to newborn. Injecting IM vastus lateralis. Don’t
forget EMLA/LMX cream (its an anesthetic cream) There’s 3 doses for this
Varicella- LIVE VACCINE! recommended for 12-15 months. Don’t get with aspirin!! Can cause
Reyes syndrome! Don’t give to cancer/chemo pt! DON’T give to patient with HIV
Inactivated polio virus/DTap: its okay to give to an immunocompromised pt. you can give to pt
who has a sibling who’s getting chemo.
Varicella zoster immune globulin (VZIG)- given to high risk children to prevent varicella!
Recommended for children who are IMMUNOCOMPROMISED and are EXPOSED to the virus,
who have no previous hx of varicella, and who are likely to contract the disease and have
complications as a result.
Therapeutic communication for patients receiving vaccinations- Need informed consents for
immunizations. VIS (vaccine information sheet)- information statements that MUST BE GIVEN
to parents before administration of given vaccines. Vaccines can be given if child has a slight
cold- not if febrile!!
Preferred immunization sites based on age- vastus lateralis or ventrogluteal muscle for infants!
Deltoid after 18 months! 1 inch needle
Use of acyclovir with varicella/chicken pox: for someone who HAS chicken pox/varicella. treat
with acyclovir to decrease the duration of the disease!
Rubella and congenital defects: mild infection in children but to the UNBORN FETUS it presents
serious problems. Its teratogenic- it affects unborn fetus! If mom is exposed to rubella, fetus is
at risk for defects.
Isolation practices for patients with chicken pox: strict isolation with AIRBORNE PRECAUTIONS.
Can go back to school once the lesions are crusted over.
Vaccine information statement (VIS): information statements that MUST BE GIVEN to parents
before administration of given vaccines
Impact of febrile illness: LIVE VIRUS is not administered to anyone with an altered immune
system or severe febrile illness.
COLLABORATION
Case Management: the ability to develop an appropriate plan of care based on assessment of
clients and families. To coordinate needed resources and services for the clients well-being
across a continuum of care. Coordinate care for multiple clients with complex issues. This
usually involves clients who are at greatest risk for needing extensive coordination of health
care services (e.g., clients with neurological disease, trauma victims, and clients with complex
medical or psychiatric conditions).
A care coordinate or manager should be appointed early in the discharge process.
Individuals present at a patient care conference: Family and key health professionals!
Roles of the case manager in coordinating multiple services: They collaborate with others in the
planning and implementation phases to ensure appropriate care after hospitalization.
STRESS & COPING
Sibling reaction to ill child: May feel guilt, jealous, or resentment toward the ill child. Sibling
may need play therapy too
Major stressor of hospitalization in younger child: major stress from middle infancy throughout
preschool years is separation anxiety
How children cope with a terminal illness diagnosis: Periods of sadness and anger are normal in
the child’s adjustment to a chronic illness. Allow the child to express their opinions, encourage
play therapy, promote normalization (let child have as much control as possible). Tell them it’s
okay to cry. Preschoolers think they caused the illness!!!
How children view hospitalization: think they caused the illness and feel guilty. They think it’s a
punishment!!!
Communication with parents: empower and enable parents to take care of child. Ask open
ended questions esp at diagnosis. Sometimes parents don’t want to tell the child about their
illness---let them know that children are ill and know when they are dying. Establish a support
system with grief to deal with the child’s illness. Assess they’re coping and if they have
family/friend support.
SATA- which shows effective coping- parent says “I know my child is dying and it hurts”, says
she’s grateful for her friend that helps her, one more?
-Parent seems asking same question- keep answering patiently
GRIEF
Children’s reaction to death:
 Preschoolers are magical thinkers. Believe their thoughts are sufficient to cause death;
the consequence is the burden of guilt, shame, and punishment. May feel guilty and
responsible for death
 School-age children still associate misdeeds or bad thoughts with causing death and feel
intense guilt and responsibility for the event. They have a deeper understanding of
death in a concrete sense. Are interested in funerals and burials, want to know what
happens to the body. Test-father is dead and parents say he’s in heaven. Child sees
father and says is this heaven?
 Adolescents have most difficulty dealing with death
Children attending funerals: it depends on the child!
Age group that has the most difficulty dealing with death: Adolescents
Helping parents and children deal with the death: If parent needs time with the child/baby—
give it to them!
Grief responses by parents: They are initially at disbelief when their child is ill, injured, or
hospitalized
SIDS (sudden infant death syndrome)
Back to sleep campaign helped raise awareness for this. Breast feeding may help prevent this
Risk factors:
 Smoking (during pregnancy or in the environment)
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Co sleeping
Prone sleeping
Prolonged QT interval
Soft bedding