1
Q
How do the following age groups experience pain?
- Infant
- Toddler
- Preschooler
- School-Age
- Adolescent
KNOW THIS!!!!
A
Infant (0-12 months): have no understanding of pain
* cry, facial grimacing, poor feeding, restlessness, irritable, disturbed sleep
Toddler (1-3 years): lack understanding of cause of pain & why it occurs
* aggressive behavior, cry, cannot describe pain intensity or type
Preschooler (3-6 years): pain = hurt; do not relate pain to illness, but may relate pain to injury
* physical resistance, aggressive behavior, easily frustrated; can identify location & intensity of pain
* may deny pain
School-Age (7-12 years): understand relationships between event / disease & pain
* clench fists, plea bargaining, may regress w/ stress & anxiety
* * can specify location & intensity of pain; able to describe physical characteristics
Adolescent (13-18 years): sophisticated & complex understanding of the causes of pain
* may immerse self in activity to distract from pain; may not express their pain to a nurse
2
Q
NIPS Pain Scale
KNOW THIS
A
Pain assessment for Infants
- > 3 or higher = pain
- Categories = facial expression, crying, breathing, arms, legs, alertness
3
Q
FLACC Pain Scale
KNOW THIS!!!!
A
Pain scale for children up to 4 years old
- 3 or above = intervention required
- categories = face, legs, activity, cry, consolability
4
Q
FACES Pain Scale
KNOW THIS!!!!!
A
Pain scale for ages 4-5 years or older
- Child points to faces based on how bad their pain is
5
Q
Numerical Pain Scale
KNOW THIS!!!!
A
Pain scale from 1-10
- used for most ages; 4-5 + OR if they can distinguish between larger & smaller numbers
6
Q
Body Pain Scale
KNWO THIS!!!!!
A
Have the child color in the area where it hurts
7
Q
Safe dose & age requirement for Motrin (ibuprofen)
KNOW THIS!!!!
A
- NOT under 6 months of age
10 mg/kg Q6h
8
Q
Safe Dose for Motrin (ibuprofen)
KNOW THIS!!!!
A
10 mg/kg q6h
9
Q
Safe Dose for Tylenol (acetaminophen)
KNOW THIS!!!!!
A
15 mg/kg q4-6 hours
10
Q
Nonpharmacological Pain Management
A
- distraction
- guided imagery
- breathing techniques
- cutanoeus stimulation
- sucrose / sugar
- heat or cold
11
Q
Principles of Pain Assessment in Children (QUESTT)
KNOW THIS!!!!!
A
- Question the child
- Use a pain rating scale
- Evaluate behavioral & physiologic changes
- Secure parent’s involvement
- Take the cause of pain into account
- Take action & evaluate results
12
Q
Conjunctivitis Nursing Management
A
- Contact precautions
- Keep eye dry & clean
- Administer ophthalmic medication
13
Q
3 Types of Conjunctivitis & Symptoms
KNOW THIS!!!!!
A
Bacterial (“Pink Eye”)
* purulent drainage; inflammed / red conjunctiva, swollen lids
Viral
* serous (watery drainage), edema of the eyelid, inflammed conjunctiva
Allergic
* intense itching,, watery to thick drainage, swollen eyes
14
Q
Viral Conjunctivitis
KNOW THIS!!!!!
A
Cause: adenovirus (respiratory infection)
S/S: serous (watery) drainage, eyelid edema, inflammed conjunctiva
Tx: antivirals & supportive care
15
Q
Allergic Conjunctivitis
KNOW THIS!!!!!
A
Cause: allergies
S/S: intense itching, watery to thick drainage, swollen eyelids
Tx: antihistamines, decongestants, lubricants
16
Q
Bacterial Conjunctivitis
KNOW THIS!!!!
A
“Pink Eye”
S/S: Purulent drainage, inflammed / red conjunctiva, swollen lids
Tx: erythromycin antibotic drops
17
Q
What is Opthalmia Neonatorum & what is the cause?
KNOW THIS!!!!
A
Conjunctivitis of the newborn (< 30 days old)
Causes: acquired vaginally from birth infections (gonorrhea, chlamydia, HSV)
18
Q
Eye Drop Administration
A
- Adequate immobilization is needed to avoid injury.
- Nurse’s hand can be stabilized by resting the wrist on the child’s head
- Explanations & therapeutic play can be used with children old enough to explain the process of administration
- Have the medication at room temperature
19
Q
What is periorbital cellulitis & what are the signs & symptoms?
KNOW THIS!!!!!
A
Bacterial infection of the eyelids & surrounding tissue
S/S:
* erythema
* tenderness
* painful movement
* fever
* red / purple eyelids
20
Q
What is the difference in pediatric ears from adults?
KNOW THIS!!!!
A
Eustachian tube is shorter & wider
- TM is easily injured
21
Q
What is otitis media? What are the signs & symptoms & what is the treatment?
KNOW THIS!!!!!
A
inflammation of the middle ear
S/S: redness (over portions of the ear drum), bulging TM, fluid w/ no movement or excessive movement
Tx: antibiotics, tympanostomy, tube placement
22
Q
Otitis Externa: what is it?
KNOW THIS!!!!
A
Inflammation of the outer ear; “swimmer’s ear”
Causes: placing things in the ears
Tx: abx ear drops or steroid drops
23
Q
What is Epistaxis & how is it treated?
KNOW THIS!!!!
A
Nose Bleed
Tx: head upright & tilted forward;
* squeeze nares below nasal bone for 10 minutes
* cotton ball with epi, thrombin, or lidocaine
- Causes: nose picking, dryness, foreign bodies, allergies, coughing, blunt trauma
24
Q
Tonsilectomy Nursing Care
KNOW THIS!!!!
A
- Promote fluids (popsicles, ice cream, slurpees)
- Ice for discomfort
- Watch for bleeding / infection
- Normal for white / yellow exudate 7 days following
25
**Signs & Symptoms of Mild Respiratory Distress**
| **KNOW THIS!!!!**
* **Restlessness**
* **↑ RR** (Tachypnea)
* **↑ HR** (Tachycardia)
* **Diaphoresis**
## Footnote
* Child is trying to compensate for 0-2 deficits & airway blockages
* vitals reflect compensation & beginning hypoxia
26
**Signs & symptoms of Moderate respiratory distress w/ early decompensation**
| **KNOW THIS!!!!**
* **Nasal flaring**
* **Retractions**
* **Grunting / Wheezing**
* **HTN**
* Anxiety, irritability, mood changes, confusion
27
**Signs & Symptoms of Severe Respiratory Distress** (respiratory failure / imminent arrest)
| **KNOW THIS!!!!**
* **SOB** (Dyspnea)
* **↓ HR** (Bradycardia)
* **Cyanosis** (late sign)
* **Stupor** (near unconsciousness) **or coma**
* child may be in a **tripod position** to help with breathing
28
**What is croup**
| **KNOW THIS!!!!**
*Broad class of upper airway illnesses* that results in **inflammation & swelling of the epiglottis & larynx, swelling extends into the trachea & larynx**
*Cause:* can be viral or bacterial
**Dx: CXR w/ Steeple sign**
29
**Signs & Symptoms of Croup**
| **KNOW THIS!!!!**
* **Fever**
* **Barking / croupy cough**
* **Insipratory stridor**
* **Retractions**
* Hoarse cry
* Cyanosis
* ↓ LOC
30
**Treatment for Croup (laryngotracheitbronchitis / LTB)**
| **KNOW THIS!!!**
* **Oral dexamethasone**
* **Nebulized epinephrine**
* **Supplemental O2** (if hypoxic)
* **Antipyretics** (PRN)
31
**Croup (/ LTB - laryngotracheitbronchitis)**
* **What is croup?**
* **Key diagnostic sign**
* **Signs & symptoms**
* **Treatment**
| **KNOW THIS!!!!**
**Inflammation & swelling of the epiglottis & larynx that extends into the trachea & larynx**
**Diagnostic Finding: Steeple Sign** on chest x-ray
**S/S: fever, croupy / barking cough, inspiratory stridor, retractions**
* *Tx:* oral dexamethasone, nebulized epinephrine, supplemental O2 (if hypoxic), antipyretics (PRN)
32
**What is a stridor?**
**High-pitched** sound generated from **partially obstructed air flow** in the **upper airway**
33
**Key finding on chest x-ray to diagnose epiglottitis**
| **Know this**
**Thumb's sign**
34
**Key finding on chest-xray to diagnose croup**
| **KNOW THIS!!!!**
**Steeple sign!!!!!**
35
**What is Respiratory Syncytial Virus (RSV)? What are the key signs & symptoms of RSV? What is the treatment?**
| **KNOW THIS!!!**
**Highly contagious respiratory virus that is a major cause of bronchiolitis** (inflammation of the bronchioles)
**Signs & Symptoms**
* **Retractions / nasal flaring / grunting**
* **Dehydration** (dry lips, ↑ HR, lethargy)
* **Crackles & wheezing**
* *Tx:* antibiotics, nebulized albuterol, chest physiotherapy (CPT), & synagis (immunoglobulin for kids < 32 weeks old)
36
**What is a high flow nasal cannula (HFNC) and how high can you put it up to?**
| **KNOW THIS!!!!**
Continuous posoitive airway pressure (CPAP)
* up to **60 L/min**
37
**What is pneumonia & what are the 3 types?**
| **KNOW THIS!!!!**
**Inflammation fo bronchioles & alveoli**
* viral, bacertial, & atypical (mycoplasmal)
38
**Key signs & symptoms of pneumonia**
| **KNOW THIS!!!!**
* **Crackles / rhonchi**
* **Chest pain**
* **Retractions / nasal flaring / grunting**
* **SOB**
* **Lethargy**
39
**What are the 3 types of pneumonia?**
| **KNOW THIS!!!!**
* bacterial
* viral
* mycoplasmal (atypical)
40
**Pneumonia**
* **What is it?**
* **What are the 3 types**
* **What are the common s/s?**
| **KNOW THIS!!!!**
inflammation of the bronchioles & alveoli
**Types:** viral, bacterial, mycoplasmal (atypical)
**S/S:**
* **Crackles / Rhonchi**
* **Chest pain**
* **Retractions**
* **Nasal flaring**
* **Grunting**
* **Tachypnea** (SOB)
* **Lethargy**
41
**Signs & symptoms of asthma**
* sudden onset of shortness of breath
* **wheezing** (inspiratory or expiratory)
* **Retractions**
42
**Short-Acting Beta Agonists (SABA) for asthma**
**Albuterol**
43
**Corticosteroids for asthma**
* **Decadron**
* **Prednisone**
* **Solumedrol**
44
**Anticholinergics for asthma**
**ipatropium**
45
**Adjuncts for asthma**
Duoneb: albuterol/ipatroopium, magnesium sulfate
46
**5-10-5 Rule for Asthma Spacers**
| **KNOW THIS!!!!**
* Tilt head back & **breath in for 5 seconds**
* **Hold breath for 10 seconds**
* **Breath out for 5 seconds**
47
**Cystic Fibrosis**
| **KNOW THE BOLD!!!!**
**Reduced water movement across cell membranes = blocked airways**
* Inherited disorder, **CFTR gene mutation,** autosomal **recessive** trait
* Causes damage to the lungs, gallbladder, pancrease, & liver
* 30,000 in the US
* 10 million carriers
**Dx: sweat test**
48
**What is 1 L of fluid loss equal to in terms of weight for a child?**
| **KNOW THIS!!!!**
**1 kg lost** (weight loss)
49
# ****
**Normal Urine Output in Children**
| **KNOW THIS!!!!**
**0.5 - 1 mL/kg/hr**
50
**Normal urine output for an INFANT**
| **KNOW THIS!!!!!**
**2 mL/kg/hr**
51
**Mild Dehydration**
| **KNOW THIS!!!**
**< / = 5% OR 40-50 mL/kg** loss of body weight
**Signs & Symptoms:**
* moist mucous membranes
* infants = irritable
* children = thirst
52
**What is considered mild dehydration?**
| **KNOW THIS!!!!**
**< / = 5% OR 40 - 50 mL/kg** loss of body weight
53
**Signs & Symptoms of mild dehydration in children**
| **KNOW THIS!!!!!**
* **Moist mucous membranes**
* **Irritable** (infants)
* **↑ thirst** (children)
54
**Moderate Dehydration**
| **KNOW THIS!!!!!**
**6 - 10% (60 - 90 mL/kg)** loss of body weight
**Signs & Symptoms**
* lethargic
* ↓ skin turgor
* dark urine & ↓ output
* dry mucous membranes
* ↑ HR
* normal or ↓ BP
55
**What is considered moderate dehydration in children?**
| **KNOW THIS!!!!**
**6 - 10% or 60 - 90 mL/kg** loss of body weight
56
**Signs & Symptoms of moderate dehydration in children**
| **KNOW THIS!!!!!**
* **lethargic**
* **↓ skin turgor**
* **dark urine & ↓ output**
* **dry mucous membranes**
* ↑ HR
* normal or ↓ BP
57
**Severe Dehydration**
| **KNOW THIS!!!!!**
**> / = 10% OR 100 mL/kg** loss of body weight
**Signs & Symptoms**
* ↑ irritability
* lethargy / non-responsive
* ↓ BP
* ↑ HR
* nonelastic skin turogor
* dry mucous membranes
* ↓ or absent urine output
58
**What is considered severe dehydration in children?**
| **KNOW THIS!!!!**
**> / = 10% OR 100 mL/kg** loss of body weight
59
**Signs & Symptoms of severe dehydration in children**
| **KNOW THIS!!!!!**
* ↑ irritability
* lethargy / non-responsive
* **↓ BP**
* **↑ HR**
* non-elastic / **poor skin turgor**
* **dry mucous membranes**
* **↓ or absent urine output**
60
**4-2-1 Rule for Fluid Maintenance** (holiday-segar method)
| **KNOW THIS!!!!**
* **First 10 kg** = **4** mL/kg/hr
* **Next 10 kg** = **2** mL/kg/hr
* **Above 20 kg** = **1** mL/kg/hr
61
**What is the bolus rate for rehydration?**
| **KNOW THIS!!!!!!**
**20 mL/kg over 30-60 minutes**
62
**Rehydration Example:**
*Jimmy is a 4 year old boy brought into the pediatric ED by his mom. He has been vomiting & having diarrhea for 4 days. You determine he has mild dehydration & your hospital recommends a sfluid deficit of 40 mL/kg/24 hours for thsi type of dehydration. He weighs 37 kg.*
**1.)** Calculate the fluids needed to correct the deficit
**2.)** Calculate the bolus amount
**3.)** Calculate the maintenance IV fluid (MIVF) rate
**1.) Calculate fluids needed to correct the deficit**
* 40 mL/kg **x** 37 kg **= 1480 mL**
**2.) Calculate the bolus amount**
* 37 kg **x** 20 mL **= 740 mL**
**3.) Calculate the MIVF Rate**
* **(**10 kg **x** 4 mL/kg/hr**) + (**10 kg **x** 2 mL/kg/hr**) + (**17 **x** 1 mL/kg/hr**) =**
* 40 mL **+** 20 mL **+** 17 mL **= 77 mL**
* **First hour he will receive 1 NS bolus of 740 mL** (20 mL/kg bolus x 37 kg = 740 mL)
**Then he will receive the remaining 740 mL** (1480 -740 = 740) **deficit over the next 23 hours**
* 740 **/** 23 hr **= 32.17 mL/hr**
* 32.17 mL **+** 77 mL **= 109 mL/hr**
63
**Rehydration Example:**
*Jimmy is a 4 year old boy brought to the pediatric ED by his mom. He has been vomiting & having diarrhea for 4 days. You determine he has mild dehydration & your hospital recommends a fluid deficit of 40 mL/kg/24hr for this type of dehydration. He weighs 37 kg.*
**Calculate the fluids needed to correct the deficit.**
40 mL/kg **x** 37 kg **= 1480 mL**
64
**Rehydration Example:**
*Jimmy is a 4 year old boy brought to the pediatric ED by his mom. He has been vomiting & having diarrhea for 4 days. You determine he has mild dehydration & your hospital recommends a fluid deficit of 40 mL/kg/24hr for this type of dehydration. He weighs 37 kg.*
**Calculate the bolus amount**
37 kg **x** 20 mL **= 740 mL**
## Footnote
* bolus is given 20 mL/kg over 30-60 minutes
65
**Rehydration Example:**
*Jimmy is a 4 year old boy brought to the pediatric ED by his mom. He has been vomiting & having diarrhea for 4 days. You determine he has mild dehydration & your hospital recommends a fluid deficit of 40 mL/kg/24hr for this type of dehydration. He weighs 37 kg.*
**Calculate the Maintenance IV fluid (MIVF) rate**
* **(** 10 kg **x** 4 mL**) + (** 10 kg **x** 2 mL/kg/hr**) + (**17 kg **x** 1 mL/kg/hr**) =**
* 40 mL **+** 20 mL **+** 17 mL **= 77 mL**
**Over the first hour he will receive 1 NS bolus of 740 mL** (20 mL/kg bolus x 37 kg = 740 mL)
.
**Then he will receive the remaining 740 mL** (1480 - 740 = 740) **deficit over the next 23 hours**
* 740 mL **/** 23 hr **= 32.17 mL/hr**
* 32.17 mL **+** 77 mL *(MIVF rate)* **= 109 mL/hr**
## Footnote
* first 10 kg **= 4** mL/kg/hr
* next 10 kg **= 2** mL/kg/hr
* above 20 kg **= 1** mL/kg/hr
66
**How to Calculate IV Fluid Replacement**
| **KNOW THIS!!!!**
**1.)** Calculate **deficit for 24 hours**
**2.)** Calculate **hourly maintenance IV fluids (MIVF)**
**3.) IV Rate =** deficit **+** MIVF
* **Replace 50% in first 8 hours**
* **Replace 50% in the next 16 hours**
67
**Oral Rehydration** (how much is given?)
| **KNOW THIS!!!!**
**1-2 tsp** of fluid **every 10-15 minutes**
68
**4-2-1 Rule Example:** Child weighs 12 kg
**1.) first 10 =** (10 kg **x 4** mL/kg/hr) = 40 mL/hr
**2.) second 10 =** (2 kg **x 2** mL/kg/hr) = 4 mL/hr
**3.) Add --** 40 mL/hr **+** 4 mL/hr **= 44 mL/hr**
69
**4-2-1 Rule Example:** child weighs 35 kg
**1.) First 10 kg =** 10 kg **x 4** mL/kg/hr **= 40 mL/hr**
**2.) Second 10 kg =** 10 kg **x 2** mL/kg/hr **= 20 mL/hr**
**3.) Above 20 kg =** 15 kg **x 1** mL/kg/hr **= 15 mL/hr**
**4.) ADD --** 40 mL/hr **+** 20 mL/hr **+** 15 mL/hr **= 75 mL/hr**
70
**Normal Sodium** (Na+) **level**
| **KNOW THIS!!!!!**
**135 - 145**
71
**Causes of Hyponatremia**
| **KNOW THIS!!!!**
* **diarrhea**
* **vomiting**
* **CHF**
* inadequate salt intake
* GI suctioning
* diuretics
## Footnote
**↓ Na+** (< 135)
72
**Signs & Symptoms of Hyponatremia**
| **KNOW THIS!!!!!**
* **NEURO CHANGES**
* ↓ BP
* Dry mucosa
* **Headache**
* Confusion
* Lethargy
* **Poor skin turgor**
* Muscle weakness
* ↓ deep tendon reflexes (DTRs)
| **Na = N**euro changes
## Footnote
**↓ Na+** (< 135)
73
**Causes of Hypernatremia**
| **KNOW THIS!!!!**
* inadequate breastfeeding intake w/ normal output
* **Diabetes Insipidus (DI)**
* excesive sweating
* ↑ aldosterone
* **Diarrhea or vomiting**
## Footnote
**↑ Na+** (> 145)
74
**Signs & Symptoms of Hyeprnatremia**
| **KNOW THIS!!!!**
* **NEURO CHANGES**
* **↑ thirst**
* **↓ urine output** (unless ↑ Na is caused by DI)
* **↓ LOC** (confusion, lethargy, coma)
* **Seizures**
| **Na = N**euro changes
## Footnote
**↑ Na** (> 145)
75
**Normal Potassium** (K+) **Levels**
| **KNOW THIS!!!!!**
**3.5 - 5**
76
**Causes of Hypokalemia**
| **KNOW THIS!!!!!**
* **GI losses (vomiting / diarrhea)**
* Medications
* poor dietary intake (starvation)
* **↑ aldosterone** (hyperaldosteronism, CHF, cirrhosis)
* ↑ cortisol (Cushing disease)
* alkalosis
## Footnote
**↓ K+** (< 3.5)
77
**Signs & Symptoms of Hypokalemia**
| **KNOW THIS!!!!**
* **Muscle weakness**
* fatgieu
* anorexia
* **Adominal distension / constipation**
* nausea / vomiting
* **Dysrhythmias**
## Footnote
**↓ K+** (< 3.5)
78
**Causes of Hyperkalemia**
| **KNOW THIS!!!!!**
* **Impaired renal function**
* crush injury
* burns
* metabolic acidosis
## Footnote
**↑ K+** (> 5)
79
**Signs & Symptoms of Hyperkalemia**
| **KNOW THIS!!!!**
* **Cardiac changes & dysrhythmias**
* lethargy
* GI symptoms (cramps & diarrhea)
* **Muscle weakness**
* ↓ BP
## Footnote
**↑ K+** (> 5)
80
**Normal Calcium** (Ca+) **Levels**
| **KNOW THIS!!!!**
**2.8 - 2.86**
81
**Causes of Hypocalcemia**
| **KNOW THIS!!!!!**
* **Malabsorption** (poor diet, vitamin D deficiency)
* alkalosis
* **Chronic diarrhea**
## Footnote
**↓ Ca+** (< 2.8)
82
**Signs & Symptoms of Hypocalcemia**
| **KNOW THIS!!!!!**
* **NEUROMUSCULAR EXCITABILITY**
* laryngospasm
* **Cardiac arrhytmias**
* dyspnea
* **Trousseau's Sign**
* seizures
* **Chvostek's Sign**
## Footnote
**↓ Ca+** (< 2.8)
83
**Causes of Hypercalcemia**
| **KNOW THIS!!!!!**
* **Bone tumors & other cancer**
* ↑ calcium absorption
* vitamin D overdose
* **Infants w/ very low birth weight who have inadequate phosphorus intake**
* Children receiving TPN
## Footnote
**↑ Ca+** (> 2.86)
84
**Signs & Symptoms of Hypercalcemia**
| **KNOW THIS!!!!!**
* **Muscle Weakness**
* incoordination
* polyuria
* **↓ neuromuscular excitability**
* ↑ thirst
* confusion
* **Constipation & N/V**
* lethargy
* ↓ attention span
* **Dysrhythmias**
| ↑ Ca+ **=** ↓ neuromuscular excitability
## Footnote
**↑ Ca+** (> 2.86)
85
**Normal Magnesium** (Mg+) **Levels**
| **KNOW THIS!!!!**
**1.6 - 2.4**
86
**Causes of Hypomagnesemia**
| **KNOW THIS!!!!!!**
* **GI losses** (N/V, diarrhea)
* enteral or parenteral feeding deficient in magnesium
* **↓ Mg Absorption** (due to chronic diarrhea, short bowel syndrome, malabsorption syndromes, & steatorrhea)
* Can also be caused by DKA, sepsis, burns, & hypothermia
* **Prolonged NG Suctioning**
## Footnote
**↓ Mg+** (< 1.6)
87
**Signs & Symptoms of Hypomagnesemia**
## Footnote
**KNOW THIS!!!!!!**
* **↑ NEUROMUSCULAR EXCITABILITY**
* hyperactive reflexes
* muscle cramps
* tremors / twitches
* **Cardiac arrhythmias**
| ↓ Mg **=** ↑ neuromuscular excitability
## Footnote
**↓ Mg+** (< 1.6)
88
**Causes of Hypermagnesemia**
| **KNOW THIS!!!!**
* **Renal failure** (oliguric renal failure & adrenal insufficiency)
* DKA
* excessive administration fo Mg
* aspiration of sea water (drowning)
* **Addison Disease**
## Footnote
**↑ Mg+** (> 2.4)
89
**Signs & Symptoms of Hypermagnesemia**
| **KNOW THIS!!!!!**
* **↓ NEUROMUSCULAR EXCITABILITY**
* drowsiness
* lethargy
* **↓ BP**
* weak / absent deep tendon reflexes
* **↓ HR**
| ↑ Mg+ **=** ↓ Neuromuscular excitability
## Footnote
**↑ Mg+** (>2.4)
90
**Respiratory Acidosis**
| **KNOW THIS!!!!!**
**↓ pH**, **↑ CO2**
## Footnote
**Causes:**
* severe asthma
* pneumonia
* hypoventilation
91
**Respiratory Alkalosis**
| **KNOW THIS!!!!!**
**↑ pH**, **↓ CO2**
## Footnote
**Causes:**
* hyperventilation
* panic attack
* aspirin toxicity
92
**Metabolic Acidosis**
| **KNOW THIS!!!!!**
**↓ pH**, **↓ HCO3**
## Footnote
**Causes:**
* DKA
* lactic acidosis
* EtOH
93
**Metabolic Alkalosis**
| **KNOW THIS!!!!!**
**↑ pH**, **↑ HCO3**
## Footnote
**Causes:**
* vomiting = loss of acid
94
**Daily Fluid Maintenance** (based on weight of child in kg)
| **KNOW THIS!!!!!**
* Usual weight: up to *10 kg* → **100 mL/kg/24 hr**
* Usual weight: *11 - 20 kg* → **1000 mL + (50 mL/kg** for weight above 10 kg**)/24 hr**
* Usual weight: *> 20 kg* → **1500 mL + (20 mL/kg** for weight above 20 kg**) / 24 hr**
95
**Daily Fluid Maintenance for a child who weighs up to 10 kg**
| **KNOW THIS!!!!!**
**100 mL/kg/24 hr**
## Footnote
*Kid is 9.5 kg*
Daily Fluids **=** 100 mL **x** 9.5 kg **= 950 mL / 24 hr**
96
**Daily Fluid Maintenance for a child who weighs 11-20 kg**
| **KNOW THIS!!!!!**
**1000 mL + (50 mL/kg** for each kg over 10 kg**) / 24 hr**
## Footnote
*Kid is 16.5 kg*
Daily Maintenance = **1000 mL + (**50 mL/kg **x** 6.5 kg**)**
**Daily Maintenance = 1,325 mL / 24 hr**
97
**Daily Fluid Maintenance for a child who weighs over 20 kg**
| **KNOW THIS!!!!!**
**1500 mL +20 mL/kg** for each kg over 20 kg**) / 24 hr**
## Footnote
*Kid weighs 55 kg*
Daily Maintenance = **1500 mL + (**20 mL/kg **x** 35 kg**) / 24 hr**
**Daily Maintenance = 2,200 mL / 24 hr**
98
**Hypopituitarism (GHD)**
| **KNOW THIS!!!!**
**↓ pituitary gland activity = ↓ growth hormone secretion**
99
**When should treatment of hypopituitarism be done?**
At night when normal hormones are secreted
100
**Precocious Puberty**
| **KNOW THIS!!!!!!!**
**Sexual development before age 9 in boys & before age 8 in girls**
* advanced bon egrowth makes them taller
* can result in stunted growth if growth plates close too soon
*Causes:* disorders of gonads, adrenals, hypothalamus releases GnRH (gonadotropin-releasing hormone)
* *80-90% of girls = no cause*
**Treatment: GnRH agonist like Lupron** (breast cancer drug) **to slow growth to normal rates**
* tx is discontinued at age fro normal pubertal changes to resume
* **failure to treat may result in stunted growth as children with precoscious puberty have advanced bone age**
101
**What is Percocious Puberty?**
| **KNOW THE DEFINITION**
**Puberty onset / sexual development before age 9 in boys & before age 8 in girls**
102
**Treatment of Precocious Puberty. What happens if precocious puberty is not treated?**
| **KNOW THIS!!!!**
**GnRH agonist like Lupron** (breast cancer drug) **which slows growth to normal rates**
* *Failure to treat may result in stunted growth as children with precocious puberty have advanced bone age*
103
**Precocious Puberty Nursing**
| **KNOW THIS!!!!!**
* **Promote Positive Body Image -** child appropriate terms
* **Provide family education -** emotional support
104
**Hypothyroidism**
| **KNOW THIS!!!!!!**
**↓ active levels of thyroid hormone**
* **newborn screen for T3/T4** (hypothyroidism can be congenital)
105
**What is the difference in primary & central hypothyroidism?**
| **KNOW THIS!!!!**
* **Primary:** thyroid problem (↑ TSH, ↓ T4)
* **Central:** hypothalamus problem (normal TSH, ↓ T4)
106
**Primary Hypothyroidism**
| **KNOW THIS!!!!1**
**THYROID** problem
* **↑ TSH**
* **↓ T4**
107
**Central Hypothyroidism**
| **KNOW THIS!!!!!**
**HYPOTHALAMUS** problem
* **normal TSH**
* **↓ T4**
108
**Signs & Symptoms of Hypothyroidism in INFANTS**
| **KNOW THE BOLD**
* thick tongue
* **Hypotonia**
* umbilical hernia
* hoarse cry
* constipation
* **Large fontanelles**
109
**Signs & Symptoms of Hypothyroidism** (or acquired thyroid dysfunction) **in Children**
| **KNOW THE BOLD!!!!**
* **↓ appetite**
* dry, cool skin
* **hair thinning**
* **↓ HR** (bradycardia)
* constipation
* ↓ DTRs
* **cold temperature sensitivity**
* **abnormal menses**
* goiter (enlarged thyroid)
110
**Hypothyroidism Treatment**
| **KNOW THIS!!!!!**
**Levothyroxine, 15 mcg/kg/day**
111
**Type 1 DM**
| **KNOW THIS!!!!**
**Body's immune system attacks beta cells & ↑ glucose level**
* **Bimodal Peaks:** diagnosis around ages 4-6 & 10-14
112
**Signs & Symptoms of Type 1 DM**
| **KNOW THE BOLD!!!!!**
* **Polyuria** (↑ urination)
* **Polydipsia** (↑ thirst)
* **Polyphagia** (↑ hunger)
* glucosuria (glucose in urine)
* glucogenesis (breaking down protein/fat for energy)
* dry skin
* rapid weight loss
* drowsiness/fatigue
* irritability
* abdominal discomfort
* ketoacidosis
113
**Type 1 DM Bimodal Peaks**
| **KNOW THIS!!!!**
Diagnosis around ages **4-6** & ages **10-14**
114
**Type 2 DM**
| **KNOW THIS!!!!**
**Insulin resistance caused by prolonged exposure to elevated glucose levels**
* controlled with diet & exercise
* Often obese or comorbid conditions such as PCOS, lipid disorders, & HTN
115
**Rapid Acting Insulin**
| **KNOW THIS!!!!!**
**Onset = 15 minutes**
* *Novolog & Humalog* **(-log)**
* eat immediately after; for meal dosing
116
**Intermediate Insulin**
| **KNOW THIS!!!!!**
**Onset = 1-3 hours**
* *NPH or Humulin N*
* is cloudy
* not often used in children
117
**Long Acting Insulin**
| **KNOW THIS!!!!**
**Insulin acts over 12-24 hours**
* *glargine (Lantus) or detemir (Levemir)*
* injections are usually done in the morning or at night
* can NOT be mixed with other insulin
118
**What is IC Ratio?**
| **KNOW THIS!!!!!**
**Amount of carbs 1 unit of insulin will cover**
*Ex:* 1 unit of insulin covers 15 g of carbs = 1:15 IC ratio
119
**How do you calculate IC ratio?**
| **KNOW THIS!!!!**
**1.) Calculate the total gram of carbs in the meal**
**2.) Divide total grams of carbs in the meal by the ratio**
120
**IC Ratio Example:**
A patient orders 45 grams of carbs for lunch. The IC ratio is 1:15. How many units of insulin should the patient receive for this meal?
45 **/** 15 **= 3 units**
121
**What is Correction Factor (CF)?**
| **KNOW THIS!!!!!!**
**Determines insulin coverage based on target glucose**
*Example:*
* target glucose = 150
* current glucose = 300
**1.) high BG - goal BG**
* 300 - 150 = 150
**2.) Divide by CF (CF = 50)**
* 150 **/** 50 = 3 units of insulin
122
**Correction Factor Example:**
Mary has Type 1 DM. Her order reads IC ratio of 1:20 & her target blood sugar is 150 with a CF of 50. You are her nurse & she is ready to order lunch. She orders a pizza slice & millk. Dietary reports that her total carbs for the meal are 85. You obtain her blood glucose & it is 300. How much insulin do you anticipate the pediatric NP to order?
**1.)** *Insulin needed for the meal* **= Carbs / IC ratio**
* 85 carbs **/** 20 **=** 4.25 units
**2.)** *Insulin needed for higher blood sugar* **= (Current BG - Target BG) / CF**
* (300 - 150) / 50
* 150 / 50 **=** 3 units
**3.) Add the insulin needed for the meal to the insulin needed for the higher blood sugar**
* 4.25 units **+** 3 units **= 7 units** *(round to nearest whole number)*
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**What level of glucose is considered to be hypoglycemia in children & neonates?**
| **KNOW THIS!!!!**
**Children:** blood glucose **< 70 mg/dL**
**Neonates:** blood glucose **< 60 mg/dL**
124
**Signs & Symptoms of Hypoglycemia**
* Blurred vision
* ↑ HR
* sweating
* tremors / shaking
* ↑ hunger
* confusion / difficulty concentrating
125
**What is the treatment for hypoglycemia?**
| **KNOW THIS!!!!!**
**If Awake = Oral Glucose** (juice, sweetner, raisins, glucose tabs)
* *recheck glucose in 15 minutes*
**Unconscious = IM, SQ, nasal glucagon OR glucose paste on gums**
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**Diabetic Ketoacidosis (DKA)**
| **KNOW THIS!!!!**
**INSUFFICIENT INSULIN for the body's demands** in a diabetic patient that **results in production of ketones (metabolic acidosis)**
* **Blood Glucose > 200**
* **Ketonuria**
* **Ketonemia**
* **pH < 7.30**
127
**Lab results that indicate Diabetic Ketoacidosis (DKA)**
| **KNOW THESE**
**Blood glucose > 200 mg/dL**
* **Ketonuria**
* **Ketonemia**
* **pH < 7.3**
128
**Signs & Symptoms of Diabetic Ketoacidosis (DKA)**
| **KNOW THIS!!!!**
* signs of dehydration
* flushed ears / cheeks
* **↑ HR**
* **Kussmaul breathing**
* **Fruity breath**
* altered mental status
* ↓ BP
* ↑ hunger
* ↑ thirst
* ↑ urination
## Footnote
* *if not treated can lead to dehydration, electrolyte imbalances, coma, & death*
129
**Monitoring & Nursing management for patients with Diabetic Ketoacidosis (DKA)**
| **KNOW THE BOLD!!!!**
* **Hourly blood glucose checks**
* ABG checks
* Serum electrolytes checks
* Serum ketone checks
* Osmolarity / urine ketones checks
* *Use SQ insulin when pH & HCO3 are normal*
130
**Turner Syndrome**
A chromosomal disorder in **females where either an X is missing,** making the person XO instead of XX, **or part of one X chromosome is deleted**
131
**Signs & Symptoms of Turner Syndrome**
* **Webbed neck**
* **Low hairline**
* **Small jaw**
* **Short stature**
* **Broad chest & widely separated nipples**
132
**Klinefelter Syndrome**
| **KNOW THIS!!!!**
A chromosomal disorder in which **males have an extra X chromsome, making them XXY instead of XY**
133
**Signs & Symptoms of Klinefelter Syndrome**
| **KNOW THIS!!!!**
* **Gynecomastia is a characteristic finding** (↑ breast gland tissue in boys)
* Puberty is delayed or an abnormal progression is evident
* **Small & firm testes**
* **Less facial & body hair may develop**
134
**Addison's Disease** (Adrenal Insufficiency)
| **KNOW THIS!!!!!**
**↓ secretion** (hyposecretion) **of aldosterone & cortisol (ACTH)**
135
**Signs & Symptoms of Addison's Disease**
| **KNOW THIS!!!!!!**
**STEROID**
* **S**odium / **s**ugar low (↓ Na / sugar)
* **T**ired
* **E**lectrolyte imbalance
* **R**eproductive changes
* l**O**w BP (↓ BP)
* **I**ncreased pigmentation
* **D**iarrhea / **d**epression
136
**Addisonian Crisis** (Adrenal crisis / acute adrenal insufficiency)
| **KNOW THIS!!!!!**
**5 S's**
* **S**evere pain
* **S**yncope
* **S**hock
* **S**uper low BP (↓↓↓ BP)
* **S**evere vomiting / diarrhea
**TX: IV cortisol**
137
**What is the treatment for Addisonian Crisis?**
| **KNOW THIS!!!!**
**IV Cortisol**
138
**Signs & Symptoms of Addisonian Crisis**
| **KNOW THIS!!!!!**
**5 S's**
* **S**evere pain
* **S**yncope
* **S**hock
* **S**uper low BP (↓↓↓ BP)
* **S**evere vomiting / diarrhea
139
**Cushing's Disease**
| **KNOW THIS!!!!**
**Hypersecretion (↑) of cortisol (ACTH)**
140
**Signs & Symptoms of Cushing's Disease**
| **KNOW THIS!!!!**
**STRESSED**
* **S**kin fragile
* **T**runcal obesity
* **R**ounded face
* **E**cchymosis
* **S**triae
* **S**ugar extremely high (↑ glucose)
* **E**xcessive bodoy hair
* buffalo hump
* **D**epression
