Pediatrics
Archer Review Crash Course
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Congenital Heart
Defects
Overview
Definition
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Abnormalities in the structure of the heart
Occur during the very beginning of gestation - the heart is formed by the
8th week of gestation!
Commonly occur with chromosomal abnormalities and syndromes such
as:
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Trisomy 21
Trisomy 18
Turners syndrome
DiGeorge syndrome
Congenital Heart Defects
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Atrial Septal Defect (ASD)
Ventricular Septal Defect (VSD)
Atrioventricular canal
Patent Ductus Arteriosus (PDA)
Tetralogy of Fallot
Tricuspid atresia
Coarctation of the aorta
Aortic stenosis
Pulmonic stenosis
Transposition of the great arteries (TGA)
Truncus arteriosus
Hypoplastic Left Heart Syndrome (HLHS)
Foramen ovale
An opening between the right and left atrium present in fetal circulation
Ductus arteriosus
An opening between the pulmonary artery and aorta present in fetal
circulation.
Assessment
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Murmurs
Left sided heart failure
Tachycardia
● Tachypnea
Diaphoresis
● Dyspnea
Decreased UOP
● Grunting
Fatigue
● Retrations
Pallor
● Nasal flaring
Cyanosis
● Cough
Clubbing
● Wheezing
Hypotension
Prolonged capillary refill
Right sided heart failure
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Weight gain
Enlarged liver
Edema
Ascites
JVD
Interventions
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Surgical interventions
Repair vs. palliation
Cardiac assist devices
Pharmacologic interventions
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Digoxin
■ Cardiac glycoside
Ace-inhibitors
■ Anti-hypertensive
Diuretics
■ Help will fluid volume overload
Beta-blockers
■ Decrease HR
NCLEX Question
Which of the following heart sounds would the nurse expect to
auscultate in her patient diagnosed with heart failure? Select all that
apply.
a.
b.
c.
d.
S1
S2
S3
S4
Answer: A, B, and C
A is correct. The nurse would expect to hear an S1 heart sound in her patient with heart failure. S1 is a normal heart
sound caused by the closing of the mitral and tricuspid valves. This heart sound should still be auscultated in a
patient with heart failure.
B is correct. The nurse would expect to hear an S2 heart sound in her patient with heart failure. S2 is a normal heart
sound produced by the closure of the aortic and pulmonic valves. This heart sound should still be auscultated in a
patient with heart failure.
C is correct. The nurse would expect to hear an S3 heart sound in her patient with heart failure. This is an abnormal
heart sound also known as a ventricular gallop. It occurs after S2 with the opening of the mitral valve, and is caused
by a large amount of blood hitting a compliant left ventricle. Because this abnormal heart sound is associated with a
large amount of blood, it is related to fluid volume overload. We see fluid volume overload in heart failure patients
whose hearts are not effectively moving blood forward. That is why S3 is heart in patients with heart failure.
D is incorrect. The nurse would not expect to hear an S4 heart sound in her patient with heart failure. S4 is also
known as an “atrial gallop” it occurs before S1 when the atria contract to force blood into the left ventricle. It is caused
by a stiff, noncompliant left ventricle.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatrics
Lesson: Cardiac
Atrial Septal
Defect
ASD
Ventricular Septal
Defect
VSD
Patent Ductus
Arteriosus
PDA
PDA
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Machine-like murmur
Can be closed surgically
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Alprostadil
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Medication that can be administered to
keep the PDA open in certain heart
defects.
This can allow blood to get out to the
body when it otherwise couldn’t.
Tetralogy of Fallot
Definition
Congenital malformation involving four distinct heart
defects: Pulmonary stenosis, right ventricular hypertrophy,
VSD, and overriding aorta.
Tet Spells
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Hypoxic spells that occur in TOF.
Begins with irritability and hyperpnea and
followed by a prolonged period of intense
cyanosis leading to syncope.
Thought to be secondary to a spasm of the
infundibulum of the outflow tract, or a drop in
systemic vascular resistance (SVR).
A drop in SVR increases the right to left shunt
and decreases pulmonary blood flow.
Tet Spell Interventions
Comfort and calm
Knee-to-chest position
Supplemental oxygen
Sedation - morphine
Volume
Sodium bicarbonate
Propranolol
Phenylephrine
Increases the SVR, which decreases R-->L shunting to increase pulmonary blood flow.
Treatment
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If mild - can go home and grow until ready for surgery
If critically ill with severe hypoxia - surgery is required in the neonatal
period.
Ideally, complete repair around 6 months of age.
Can be earlier depending on signs and symptoms.
Repair
1.
2.
3.
Pulmonary stenosis repaired by resecting the infundibular muscle
Patch closure of VSD
Pulmonary artery is opened and a patch placed to open up the outflow
tract obstruction.
NCLEX Question
Which of the following statements about the heart defect tetralogy of
fallot are true? Select all that apply.
a. There is no permanent repair for tetralogy of fallot.
b. In tetralogy of fallot, the right ventricle is enlarged due to
pulmonary stenosis.
c. Tetralogy of fallot is an acyanotic heart defect
d. Morphine may be given to the child experiencing a tet spell.
Answer: B and D
A is incorrect. There is a total repair for tetralogy of fallot. It is usually completed around 6 months of age, unless the
child's status requires intervention sooner. In this surgery, the pulmonary stenosis is repaired by resecting the
infundibular muscle. There is a patch closure of VSD, and the pulmonary artery is opened and a patch placed to open
up the outflow tract obstruction. This stops right to left shunting, and allows blood to easily flow to the lungs.
B is correct. In tetralogy of fallot, the right ventricle is enlarged due to pulmonary stenosis. The pulmonary stenosis
makes it very hard for the right ventricle to pump blood out to the lungs. This puts an extra workload on the right side
of the heart, and therefore causes the muscle of the right ventricle to hypertrophy.
C is incorrect. Tetralogy of fallot is a cyanotic heart defect, not acyanotic. In TOF, deoxygenated blood from the right
side of the heart shunts through the VSD and to the overriding aorta, where it is distributed to the body. This
distribution of deoxygenated blood causes cyanosis.
D is correct. Morphine may be given to the child experiencing a tet spell. This intervention calms the child, decreases
pulmonary vascular resistance, therefore increasing blood flow to the lungs to increase oxygenation and relieve the
tet spell.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatrics
Lesson: Cardiac
Coarctation of the
Aorta
Definition
Congenital cardiac condition characterized by a
constriction of the descending aorta.
Repair
Specific findings
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Upper extremities
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Bounding pulses
Hypertensive
Warm
Pink
Lower extremities
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Weak or absent pulses
Hypotensive
Pale
Cool
NCLEX Question
Which of the following assessment findings would lead the nurse to believe
her patient could have a coarctation of the aorta? Select all that apply.
a.
b.
c.
d.
+1 radial pulses and +3 femoral pulses
Pale, cool feet and legs with warm pink hands and arms
Hypertensive brachial blood pressure
Hypotensive popliteal blood pressure
Answer: B, C, and D
A is incorrect. In coarctation of the aorta, there is a stricture in the aorta preventing blood flow out of the left
ventricle. It usually occurs beyond the blood vessels that branch off to your upper body and before the blood vessels
that lead to your lower body. So blood flow to the upper body is abundant, but hardly any can make it to the lower
part of the body. Therefore, there are decreased lower extremity pulses, and increased upper extremity pulses. So
the nurse would expect to palpate bounding +3 or +4 pulses in the radial pulse, but weak +1 or even absent femoral
pulses. This is all due to the stricture in the aorta preventing blood flow from getting to the lower extremities.
B is correct. Pale, cool feet and legs with warm pink hands and arms would be expected in a patient with coarctation
of the aorta due to the stricture in the aorta preventing blood flow from getting to the lower extremities.
C is correct. A hypertensive brachial blood pressure would be expected in a patient with coarctation of the aorta due
to the stricture in the aorta preventing blood flow from getting to the lower extremities.
D is correct. A hypotensive popliteal blood pressure would be expected in a patient with coarctation of the aorta due
to the stricture in the aorta preventing blood flow from getting to the lower extremities.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatrics
Lesson: Cardiac
Transposition of
the Great
Arteries
Definition
A switch of the the aorta and pulmonary artery. The aorta
is coming off of the RV and the pulmonary artery is coming
off of the LV. Creates two parallel and separate tracks.
Repair
Balloon atrial septostomy - Creation of ASD to allow shunting in the
unprepared TGA patient.
Arterial switch
NCLEX Question
The LPN is discussing transposition of the great arteries with a family whose 2 day old son just
received this diagnosis. Which of the following statements by the father indicates to the nurse that
he understands his son’s condition? Select all that apply.
a.
b.
c.
d.
“Instead of the pulmonary artery attaching to the right ventricle like it should, it is
attached to the left ventricle. And the aorta is attached to the right ventricle instead of the
left ventricle.”
“Oxygenated blood from the lungs is recirculating on the right side of my son’s heart, and
deoxygenated blood is re-circulating on the left side.”
“Instead of the pulmonary artery attaching to the left ventricle like it should, it is attached
to the right ventricle. And the aorta is attached to the left ventricle instead of the right
ventricle.”
“Oxygenated blood from the lungs is recirculating on the left side of my son’s heart, and
deoxygenated blood is re-circulating on the right side.”
Answer: A and D
A is correct. This correctly explains transposition of the great arteries. In a healthy heart, the pulmonary artery
attaches to the right ventricle and the aorta to the left ventricle. In transposition of the great arteries they are
switched.
B is incorrect. This statement would not indicate that the father understands transposition of the great arteries. This
incorrectly explains the pattern of blood flow present in transposition of the great arteries. This LPN should reinforce
that the right side of the heart is recirculating deoxygenated blood and the left side of the heart is recirculating
oxygenated blood.
C is incorrect. This statement would not indicate that the father understands transposition of the great arteries. In a
healthy heart, the pulmonary artery attaches to the right ventricle and the aorta to the left ventricle. In transposition
of the great arteries they are switched. The father has this reversed, and the LPN should reinforce education on
transposition of the great arteries with him.
D is correct. This correctly explains the pattern of blood flow present in transposition of the great arteries. This
father understands that the right side of the heart is recirculating deoxygenated blood and the left side of the heart is
recirculating oxygenated blood.
NCSBN Client Need:
Topic: Health promotion and maintenance Subtopic:
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatrics
Lesson: Cardiac
Hypoplastic Left
Heart Syndrome
Definition
Disorder including 4 components: mitral stenosis or
atresia, aortic stenosis or atresia, coarctation, and a
hypoplastic left ventricle.
Repair
NCLEX Question
Which of the following defects are part of the diagnosis Hypoplastic Left Heart
Syndrome (HLHS)? Select all that apply.
a.
b.
c.
d.
Atretic mitral valve
Hypoplastic right ventricle
Atretic tricuspid valve
Hypoplastic left ventricle
Answer: A and D
A is correct. HLHS is a disorder including 4 components: mitral stenosis or atresia, aortic
stenosis or atresia, coarctation, and a hypoplastic left ventricle. An atretic mitral valve is part
of the diagnosis.
B is incorrect. There is not a hypoplastic right ventricle in HLHS. Instead there is a hypoplastic
left ventricle.
C is incorrect. There is not an atretic tricuspid valve in HLHS. There is mitral stenosis or
atresia, and aortic stenosis or atresia, but the tricuspid valve is intact and functioning.
D is correct. HLHS is a disorder including 4 components: mitral stenosis or atresia, aortic
stenosis or atresia, coarctation, and a hypoplastic left ventricle. A hypoplastic left ventricle is
part of the diagnosis.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatrics
Lesson: Cardiac
Break
Back at...
Cleft lip and Cleft
Palate
Cleft Lip
A congenital abnormality
where there is a slip, or
gap, in the upper lip on
one or both sides.
Cleft Palate
A congenital abnormality where there is a split, or gap, in the hard palate (the
roof of the mouth)
Assessment
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Visible defect
Monitor respiratory status
Airway patency
Nutritional status
Weight gain
Hydration
Complications
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Feeding difficulties
Weight loss
Failure to thrive
Speech and language delays
Hearing issues
Ear infections
Aspiration
Management
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Surgically corrected
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Pre-operative care
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Cleft lip first at 3-6 months of age
Cleft palate second at 6-24 months of age
Monitor for aspiration
Assess airway patency frequently
Post-operative care
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Positioning:
■ Position upright for feedings
■ Cleft palate - can be prone post op to help drain secretions
■ Cleft lip should NOT be prone as this could disturb the suture line
Protect suture line
Elbow restraints to avoid toddler putting things in the mouth that would compromise the
sutures
No hard foods, straws, pacifiers, etc.
No oral or nasal suctioning
Feedings
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Specialized bottle to facilitate a good suction/latch
Small, frequent feedings
Upright position
Burp frequently - will swallow a lot of air
May take longer to feed than other children
Monitor for aspiration
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At risk for feeding to go out of their nose.
NCLEX Question
While assisting the intra-disciplinary team with interventions for a toddler who has just
had a cleft palate repair, the nurse knows which of the following are appropriate? Select
all that apply.
a.
b.
c.
d.
Pacifier with oral sucrose to reduce postoperative pain
Elbow restraints
Specialized bottle for feedings
Prone positioning
Answer: B, C, and D
A is incorrect. It is not appropriate to offer a toddler who is postoperative from a cleft palate repair a pacifier. This is
because there is an incision with sutures in the palate of the mouth, and placing an object there could compromise
the site. If the sutures break, the surgical site could open back up.
B is correct. Applying elbow restraints is an appropriate intervention for a toddler who has just had a cleft palate
repair. Toddlers are often putting things in their mouths, and pulling on things. It is a priority to protect their sutures,
and we do not want the toddler to be able to pull out the sutures or put anything in their mouth that would
compromise the suture line. Therefore, elbow restraints are often needed and an appropriate intervention.
C is correct. Providing specialized bottles to the toddler who has completed their cleft palate repair will be very
important for helping them establish feedings. It will be difficult for them to get good suction on a normal bottle, so
specialized ones are needed.
D is correct. Prone positioning is appropriate for the infant with cleft palate repair post-operatively to aid in drainage
of secretions and maintenance of a patent airway.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatric
Lesson: Endocrine
Omphalocele
What is omphalocele?
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Congenital abnormality where
the abdominal contents
protrude through the
umbilicus while remaining in
the peritoneal sac.
Occurs during weeks 9-10 of
gestation.
Usually diagnosed on a
prenatal ultrasound.
Assessment
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Visible defect
Some infants have
only the omphalocele
Some also have
cardiac defects
Lung size can be
affected
Complications
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Hypothermia
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Dehydration
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Sepsis
Surgical repair
Management
Pre-op
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Keep exposed intestines moist
Cover with sterile gauze soaked
in saline
IV fluids
IV antibiotics
Thermoregulation
Post-op
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Parenteral feeds
Trophic feeds started enterally
very gradually
Monitor weight
Very long hospital stay
Gastroschisis vs.
Omphalocele
NCLEX Question
The nurse observes a parent swaddling their infant with an unrepaired omphalocele.
Which of the following statements would be appropriate?
a.
b.
c.
d.
“Stop, you’ll kill your baby!!”
“That is a nice, tight swaddle. It will really help sooth your new baby”
“May I help you? We will need to be careful with their intestines, we do not
want the swaddle to push them back inside.”
“Swaddling is not allowed for these babies, please stop.”
Answer: C
A is incorrect. This is inappropriate to say to a parent as it would cause panic and upset them. The nurse wants to
promote the parent bonding with their infant, and phrases like this will scare the parent and make them afraid to
touch the baby, which is not therapeutic.
B is incorrect. It is not appropriate to tightly swaddle an infant with an omphalocele. This would place pressure on
their exposed intestines and could push them back inside of the baby, which we do not want.
C is correct. This is a therapeutic statement. It educates the parent about the need to swaddle the baby only very
loosely, and avoid any pressure on the exposed intestines so that they do not get pushed back inside of the baby. It
also promotes bonding with the infant, as it encourages the parent to touch and care for their baby.
D is incorrect. This is not appropriate. Swaddling is not ideal for an infant with an omphalocele due to the exposed
intestines, but if it is done loosely and avoids placing pressure on the defect it can certainly be done. Telling the
parent to stop will not promote bonding and decrease their interaction with the baby. The nurse should educate the
parent on the necessary precautions when traveling and help them develop a positive relationship with their new
baby.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatric
Lesson: Gastrointestinal
Intussusception
What is Intussusception?
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Occurs when one part of the intestine slips inside the other intestine
“Telescoping”
Often occurs where the small intestine and large intestine meet.
Assessment
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Red currant jelly
stools
Cyclical abdominal
pain
Nausea
Vomiting
Green, bilious emesis
Sausage-shaped
mass in abdomen
Treatment
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Enema to attempt to push the
intestine back out
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Air enema
Hydrostatic enema
Barium enema
If successful a surgical repair is
needed.
Management
Pre-op
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Monitor stool
NPO
IV fluids
IV antibiotics
Post-op
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Monitor bowel function
Infection is common
complication
○ Monitor temps, WBCs, CRP
Slowly advance diet
NCLEX Question
Which of the following symptoms should the nurse monitor for in her patient
suspected of intussusception? Select all that apply.
a.
b.
c.
d.
Red currant jelly stool
Hematemesis
Palpable, sausage-shaped mass in RUQ
Steatorrhea
Answer: A and C
A is correct. Red currant jelly stool is a classic finding of intussusception. When the bowel telescopes
into another portion of the intestine, it causes intestinal obstruction and subsequently red currant
jelly stools.
B is incorrect. Hematemesis, or bloody vomiting, is not an expected finding in intussusception. We
would expect vomiting of gastric contents, and possibly green bile if there is an obstruction.
C is correct. Palpable, sausage-shaped mass in RUQ is a classic finding of intussusception. This is
due to the physical telescoping of the intestine and the mass can sometimes be felt on palpation.
D is incorrect. Steatorrhea is the passage of oily, pale, foul-smelling stool. It indicates fat
malabsorption and can be a sign of Celiac disease, but would not be present in a patient with
intussusception.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatric
Lesson: Endocrine
Epiglottitis
What is epiglottitis?
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Inflammation of the epiglottis
Epiglottis
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A leaf-shaped flap in the throat that prevents food from entering the windpipe
and the lungs. It stands open during breathing, allowing air into the larynx
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Inflammation restricts the airway
Caused by an infection
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Haemophilus influenzae type b
Medical emergency
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Bacterial
Assessment
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Fever
Difficulty swallowing
Drooling
Stridor
Tripoding
No cough
Change in LOC
Cherry red epiglottis
The 4 D’s of epiglottitis
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Dysphagia
Dysphonia
Drooling
Distress
Treatment
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IV antibiotics
Humidified oxygen
Intubation and mechanical
ventilation
Keep the child calm
No interventions until airway is
secure
Do not irritate the throat
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Tripod position
Avoid supine
NO tongue depressor
NO oral thermometer
NO assessing the throat
NPO
Education
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Hib vaccine has reduced incidence
Encourage parents to vaccinate to prevent
When to call 911
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Trouble swallowing, breathing, and talking
Straining the neck forward (trying to open the airway)
Drooling (when it becomes too painful to swallow)
A harsh raspy sound when inhaling (stridor), a sign that the airways are blocked
Blue, purple, or gray skin or lips
Trouble waking up to awake or arouse or unresponsive
Trouble breathing
NCLEX Question
The nurse is assessing a 4 year old who was sent to the ED from urgent care. Assessment
reveals tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling.
Vital signs are:
Temp: 39 C
HR: 188
RR: 46
O2: 82 %
Which of the following is the priority nursing action at this time?
a.
b.
c.
d.
Keep the child calm and call for emergency airway equipment
Obtain IV access
Assess the throat for a cherry red epiglottis
Place the child on a high flow nasal cannula at 100% FiO2
Answer: A
A is correct. Based on the presenting symptoms, the nurse suspects that this child has epiglottitis. Any child presenting with
excessive drooling, distress, and stridor is highly suspicious for this medical emergency. In addition, this patient is already
showing signs of circulatory compromise including circumoral cyanosis and mottling. The priority nursing action in this
emergency is keeping the child calm and calling for emergency airway equipment. The child is at risk of losing their airway, and
airway is always the priority!
B is incorrect. It is inappropriate to attempt to obtain IV access on a child suspected of epiglottitis before emergency airway
equipment is available. The priority action at this time is keeping the child calm and calling for emergency airway equipment.
C is incorrect. It is inappropriate to assess the throat for a cherry red epiglottis at this time. Although presence of a cherry red
epiglottis would confirm the diagnosis of epiglottitis, this child is at risk of losing their airway. The priority action will be to
protect that airway before assessing the throat. .
D is incorrect. Placing the child on a high flow nasal cannula at 100% FiO2 is not the priority at this time. This answer probably
sounded right, because you see the O2 is 82% and they have circumoral cyanosis. Oxygen sounds like the right answer! But this
intervention addresses the ‘C’ in your ABC’s - circulation. And the priority is always ‘A’, airway! This child is at risk of losing their
airway, so all interventions need to wait until there is emergency airway equipment close by. If anything upsets the child their
airway could spams and obstruct completely making it impossible to intubate them. That is why keeping the child calm and
calling for emergency airway equipment is the priority in epiglottitis patients.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatric
Lesson: Respiratory
RSV/Bronchiolitis
What is bronchiolitis?
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Inflammation of the bronchioles
Bronchioles
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Alveoli
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Smallest branches of the airway
Lead to alveoli
Air sacs
Location of gas exchange in the lungs
Thick mucus clogs up the
bronchioles
Leads to decreased gas exchange
in alveoli
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○
Air trapping
Collapsed alveoli
Overview
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Most common in children under 2 years old
Seasonal illness
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Causative agent usually viral
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Most common in winter
Respiratory Syncytial Virus (RSV)
Very contagious
Worst on days 4-6
Assessment
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Cough
Fever
Increased work of breathing
○
○
○
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Retractions
■ Subcostal
■ Intracostal
■ Tracheal tug
Nasal flaring
Head bobbing
Tachypnea
Lung sounds
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Crackles
Wheezing
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Hypoxia
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Circumoral cyanosis
Mottling
Delayed capillary refill
Decreased SpO2
Changes in behavior
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Irritability
Lethargy
Poor feeding
Treatment
Supportive treatment
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Oxygenation
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Fluid & Nutrition
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○
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Nasal cannula - high flow nasal cannula
Always humidified
NGT
Enteral feedings
IVF
Antipyretics
Analgesics
Nursing Considerations
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Continue to monitor respiratory status for changes
○
○
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Work of breathing - improving? Worsening?
Continuous pulse oximetry
Maintain airway at all times
○
○
○
Semi fowlers preferred positioning
Keep neck extended to open airway
■ Shoulder roll
Suction available
Education
●
Infection prevention
○
○
●
Droplet precautions
Isolate from others as able at home
Prevention
○
Palivizumab for at risk patients
■ Synagis
■ Premature infants
■ CF
■ Trisomy 21
NCLEX Question
The nurse is assigned to care for a 18 month old diagnosed with bronchiolitis. She was
born at 32 weeks gestation, but has no other past medical history. Which of the
following does the nurse anticipate including in the plan of care?
a.
b.
c.
d.
Ceftriaxone administration
Humidified oxygen administration
Contact precautions
IV fluids
Answer: B and D
A is incorrect. Bronchiolitis is usually caused by a viral infection, most commonly respiratory syncytial virus (RSV).
Ceftriaxone is an antibiotic, and antibiotics will not be effective against viral infections for they are not supported in
the treatment of bronchiolitis.
B is correct. Treatment of bronchiolitis will be primarily symptom management. Many children will require oxygen
administration as the mucous in their bronchioles lessens gas exchange in the alveoli. Oxygen administration should
be humidified to prevent drying out the mucous membranes.
C is incorrect. Contact precautions are not sufficient for bronchiolitis. This infection is likely caused by a respiratory
virus such as RSV and spread through droplets in the air, so droplet precautions will be necessary. This will include a
gown, gloves, and mask when the nurse enters the room. Frequent handwashing is also key to preventing the spread
of this infection.
D is correct. Due to the increased work of breaking that bronchiolitis causes, IV fluid administration may be
necessary in the treatment of bronchiolitis if the patient is unable to meet their fluid requirements through PO intake.
An isotonic crystalloid solution will be used to ensure the patient remains hydrated until they can safely take PO fluids
again.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Basic care, comfort
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatric
Lesson: Respiratory
Cystic Fibrosis
What is Cystic Fibrosis?
●
●
●
Autosomal recessive disorder
Mutation leads to a buildup of excessive mucus in the airways
Mucus leads to airway obstruction
Pathophysiology
●
●
Mucus is both excessive and very thick
Causes mechanical obstructions throughout the body
○
○
○
○
Bronchi
Small intestines
Pancreatic ducts
Bile ducts
Testing
●
Newborn screening
○
○
●
Sweat chloride test
○
○
●
Meconium ileus
■ Meconium is thicker and stickier than normal, creates a blockage and first stool
doesn’t pass.
Test for elevated levels of immunoreactive trypsinogen
■ Substance normally produced by the pancreas and released into the small intestine
Sweat is collected and analyzed for increased levels of chloride
Sweat tastes salty
Genetic testing
○
○
DNA analyzed
Mutation present
Assessment
●
Respiratory
○
○
○
●
Excessive mucus
Frequent respiratory infections
Hypoxemia
■ Clubbing
■ Cyanosis
■ Barrel chest
Gastrointestinal
○
○
○
○
Intestinal obstruction
Meconium ileus
Large, bulky, frothy, foul smelling stool
Fat soluble vitamin deficiency
■ ADEK
■ Malnutrition
■ Failure to thrive
●
Endocrine
○
●
Integumentary
○
○
●
Diabetes
Salty tasting sweat
Elevated chloride in sweat
Reproductive
○
Males are infertile
Treatment
●
Airway clearance
○
○
●
Respiratory infections
○
○
○
●
Monitor for
Treat with IV antibiotics
Prevent!
Respiratory support
○
○
●
Chest physiotherapy
Vest therapy
Monitor work of breathing
Oxygen as needed
●
Promote nutrition and growth
○
○
○
○
High calorie, high protein diet
Increased fluid intake
Monitor serial weights
Pancreatic enzymes
■ Give within 30 min of eating every
meal and snack
■ Sprinkle capsules on food
■ Fat soluble vitamin replacement
Bronchodilators
NCLEX Question
The nurse is working in the normal newborn nursery. When she observes which of the
following signs, she would suspect cystic fibrosis and notify the healthcare provider for
further testing?
a.
b.
c.
d.
Steatorrhea
Hyperhidrosis
Meconium Ileus
Barrel chest
Answer: C
A is incorrect. Steatorrhea are stools that are bulk, frothy, and foul smelling. They are caused by the excretion of
abnormal quantities of fat in the stool. This does occur in cystic fibrosis, but would not be present yet in a newborn
just being diagnosed.
B is incorrect. Hyperhidrosis is a medical condition in which a person sweats excessively and unpredictably. This is not
a sign of cystic fibrosis in the newborn. The newborn with cystic fibrosis will have elevated levels of chloride in their
sweat, causing it to taste salty, but they will not sweat excessively.
C is correct. Meconium Ileus is very frequently the first sign of cystic fibrosis in a newborn. It is a bowel obstruction
that occurs when the infant’s first stool is thicker and stickier than usual, causing a blockage in the ileum.
D is incorrect. Barrel chest is a long term complication of cystic fibrosis, but not a sign that would be present at birth
in the newborn. Barrel chest refers to a broad, deep chest that is large and cylindrical. It occurs when the patient has
been suffering from hypoxemia due to cystic fibrosis for a prolonged period of time.
NCSBN Client Need:
Topic: Effective, safe care environment Subtopic: Coordinated care
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatric
Lesson: Respiratory
Cerebral Palsy
What is Cerebral Palsy?
●
●
●
A motor disability that appears in early childhood
Affects the child’s ability to move, and maintain balance and posture
It is the most common permanent physical disability in kids
Pathophysiology
●
Damage to areas of the brain that control movement
○
○
○
●
Cerebellum
Motor cortex
Basal ganglia
Causes:
○
○
○
○
Anoxia
Meningitis
TBI
Intracranial hemorrhage
Assessment
●
●
●
Abnormal movements
Poor muscle tone
Abnormal postures
○
●
Contractures
Chronic respiratory infections
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