What are the expected reproductive assessment findings in a 6-month-old infant male Quizlet

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ANS: A
The id is functioning. The id (i.e., basic instinctual impulses driven to achieve pleasure) is the most primitive part of the personality and originates in the infant. The infant, in this case the patient, cannot tolerate delay and must have needs met immediately. The ego represents the reality component, mediating conflicts between the environment and the forces of the id. The ego helps people judge reality accurately, regulate impulses, and make good decisions. The third component, the superego, performs regulating, restraining, and prohibiting actions. Often referred to as the conscience, the superego is influenced by the standards of outside social forces (e.g., parent or teacher). The child fantasizes about the parent of the opposite sex as his or her first love interest, known as the Oedipus or Electra complex. By the end of this stage, the child attempts to reduce this conflict by identifying with the parent of the same sex as a way to win recognition and acceptance.

19. A nurse works on a pediatric unit and is using a psychosocial developmental approach to child care. In which order from the first to the last will the nurse place the developmental stages?
1. Initiative versus guilt
2. Trust versus mistrust
3. Industry versus inferiority
4. Identity versus role confusion
5. Autonomy versus shame and doubt

a. 2, 5, 3, 1, 4
b. 2, 1, 3, 5, 4
c. 2, 3, 1, 5, 4
d. 2, 5, 1, 3, 4

ANS: A
Adults facilitate infant learning by planning activities that promote the development of milestones and by providing toys that are safe for the infant to explore with the mouth and manipulate with the hands, such as rattles, wooden blocks, plastic stacking rings, squeezable stuffed animals, and busy boxes. For the toddler (not the infant), television, videos, electronic games, and computer programs help support development and learning of basic skills. Infants are not capable of participating in small group activities. By age 4, children play in groups of two or three. Adults should provide toys that are safe for the infant to explore with the mouth. Small, plastic letters and magnets could be choking hazards for an infant.

Sets with similar terms

Visual acuity - May be difficult to assess in children younger than 3 years of age

Visual acuity in infants can be assessed by holding an object in front of the eyes and checking to see whether the infant is able to fix on the object and follow it.

Use the tumbling E or HOTV test to check visual acuity of children who are unable to read letters and numbers.

Older children should be tested using a Snellen chart or symbol chart.
- Color vision should be assessed using the Ishihara color test or the Hardy-Rand-Rittler test. The child should be able to correctly identify shapes, symbols, or numbers.

Eyebrows should be symmetric and evenly distributed from the inner to the outer canthus.

Eyelids should close completely and open to allow the lower border and most of the upper portion
of the iris to be seen.

Eyelashes should curve outward and be evenly distributed with no inflammation around any of the hair follicles.

☐ Object permanence - The process by which infants know that an object still exists when it is
out of view. This occurs at approximately 9 months of age.

■ Pronounces single-syllable words.
■ Begins speaking two-word phrases and progresses to speaking three-word phrases.
■ Says three to five words and comprehends "no" by the age of 1 year

■ Separation anxiety begins around 4 to 8 months of age. Infants will protest when separated from parents, which can cause considerable anxiety for parents.
■ Stranger fear becomes evident between 6 and 8 months of age, when infants are less likely to
accept strangers.

Appropriate toys and activities that stimulate the senses and encourage development include
the following.
■ Rattles
■ Teething toys
■ Nesting toys
■ Playing pat-a-cake
■ Playing with balls
■ Reading books
■ Mirrors
■ Brightly colored toys
■ Playing with blocks

■ Iron supplements are recommended for infants who are being exclusively breastfed after the age of 4 month

◯ Solids are introduced around 4 to 6 months of age.
■ Indicators for readiness include interest in solid foods, voluntary control of the head and trunk,and disappearance of the extrusion reflex
■ New foods should be introduced one at a time, over a 4- to 7-day period, to observe for signs of allergy or intolerance, which may include fussiness, rash, vomiting, diarrhea, and constipation.
■ Vegetables or fruits are started first between 6 and 8 months of age. After both have been
introduced, meats may be added.

◯ Infant sleeps 14 to 15 hr daily and 9 to 11 hr at night around the age of 4 months.

■ Hot water thermostats should be set at or below 49° C (120° F).

FLACC (2 months to 7 years)
› Face (F)
0 - Smile or no expression
1 - Occasional frown or grimace,withdrawn
2 - Frequent or constant frown,
clenched jaw, quivering chin

› Legs (L)
0 - Relaxed or normal position
1 - Uneasy, restless, tense
2 - Kicking or legs drawn up

› Activity (A)
0 - Lying quietly, moves easily,
normal position
1 - Squirming, shifting, tense
2 - Arched, ridged, or jerking

› Cry (C)
0 - No cry
1 - Moans or whimpers,
occasional complaints
2 - Crying, screaming, sobbing,
frequent complaints

› Consolability (C)
0 - Content or relaxed
1 - Reassured by occasional touching, or hugging. Able to distract
2 - Difficult to console or comfort

FACES (3 years and older)
› Pain rated on a scale of 0 to 5 using a diagram of six faces

Oucher (3 to 13 years)
› Pain rated on a scale of 0 to 5 using six photographs

Numeric scale (5 years and older)
0-10
Non-communicating children's pain checklist (3 to 18 years)
› Behaviors are observed for 10 min.

● Separation anxiety during hospitalization manifests in three behavioral responses.
◯ Protest (screaming, clinging to parents, verbal and physical aggression toward strangers)
◯ Despair (withdrawl from others, depression, decreased communication, developmental regression)
◯ Detachment (interacts with strangers, forms new relationships, appears happy)

Play allows children to express feelings and fears.
● Play facilitates mastery of developmental stages and assists in the development of problem
solving abilities.
● Play allows children to learn socially acceptable behaviors.
● Play activities should be specific to each child's stage of development.
● Play can be used to teach children.
● Play is a means of protection from everyday stressors

● Infants
◯ Birth to 3 months - colorful moving mobiles, music/sound boxes
◯ 3 to 6 months - noise-making objects and soft toys
◯ 6 to 9 months - teething toys and social interaction
◯ 9 to 12 months - large blocks, toys that pop apart, and push-and-pull toys
● Toddlers
◯ Cloth books, puzzles with large pieces
◯ Large crayons and paper
◯ Push-and-pull toys, balls
◯ Tricycles
◯ Educational television
◯ Videos for children
● Preschoolers
◯ Imitative and imaginative play
◯ Drawing, painting, riding a tricycle, swimming, jumping, and running
◯ Educational television and videos
School-age children
◯ Games that can be played alone or with another person
◯ Team sports
◯ Musical instruments
◯ Arts and crafts
◯ Collections
● Adolescents
◯ Team sports
◯ School activities
◯ Reading and listening to music
◯ Peer interactions

Infants/toddlers
(birth to 3 years)
› Have little to no concept of death
› Egocentric thinking prevents their understanding death (toddlers)
› Mirror parental emotions (sadness, anger, depression, anxiety)
› React in response to the changes brought about by being in the hospital
(change of routine, painful procedures, immobilization, less independence,
separation from family)
› May regress to an earlier stage of behavior

Preschool children
(3 to 6 years)
› Egocentric thinking
› Magical thinking allows for the belief that thoughts can cause an event such as
death (as a result, child may feel guilt and shame)
› Interpret separation from parents as punishment for bad behavior
› View dying as temporary because of the lack of a concept of time and because
the dead person may still have attributes of the living (sleeping, eating, breathing)

School-age children
(6 to 12 years)
› Start to respond to logical or factual explanations
› Begin to have an adult concept of death (inevitable, irreversible, universal),
which generally applies to older school-age children (9 to 12 years)
› Experience fear of the disease process, the death process, the unknown, and
loss of control
» Fear often displayed through uncooperative behavior
› May be curious about funeral services and what happens to the body after death

Adolescents
(12 to 20 years)
› May have an adultlike concept of death
› May have difficulty accepting death because they are discovering who they are,
establishing an identity, and dealing with issues of puberty
› Rely more on peers than the influence of parents, which may result in the reality
of a serious illness causing adolescents to feel isolated
› May be unable to relate to peers and communicate with parents
› May become increasingly stressed by changes in physical appearance due to
medications or illness than the prospect of death
› May experience guilt and shame

The presence of petechia or a purpuric-type rash requires immediate medical attention.

Isolate the client as soon as meningitis is suspected, and maintain droplet precaution

Corticosteroids - dexamethasone (Decadron)
Not indicated for viral meningitis.
Assists with initial management of increased ICP, but may not be effective for
long-term complications.

Monitor for signs of increased ICP.
Infants - bulging or tense fontanels, increased head circumference, high-pitched cry, distended scalp veins, irritability, bradycardia, and respiratory changes

Children - increased irritability, headache, nausea, vomiting, diplopia, seizures, bradycardia,and respiratory changes

Provide interventions to reduce ICP (positioning; avoidance of coughing, straining, and bright
lights; minimizing environmental stimuli).

Newborns
No illness is present at birth, but it progresses within a few days.
Clinical manifestations are vague and difficult to diagnose.
Poor muscle tone, weak cry, poor suck, refuses feeding, and vomiting or diarrhea
Possible fever or hypothermia
Neck is supple without nuchal rigidity.
Bulging fontanels are a late sign.

3 months to 2 years
Seizures with a high-pitched cry
Fever and irritability
Bulging fontanels
Possible nuchal rigidity
Poor feeding
Vomiting
Brudzinski's and Kernig's signs not reliable for diagnosis

2 years through adolescence
Seizures (often initial sign)
Nuchal rigidity
Positive Brudzinski's sign (flexion of extremities occurring with deliberate flexion of the child's neck)
Positive Kernig's sign (resistance to extension of the child's leg from a flexed position)
Fever and chills
Headache
Vomiting
Irritability and restlessness that may progress to drowsiness, delirium, stupor, and coma
Petechia or purpuric type rash (seen with meningococcal infection)
Involvement of joints (seen with meningococcal and Hib)
Chronic draining ear (seen with pneumococcal infection)

Instruct the client to remain in bed for 4 to 8 hr in a flat position to prevent leakage and a
resulting spinal headache. This may not be possible for an infant, toddler, or preschooler

Seizures are abnormal, excessive electrical discharges of neurons within the brain caused by a disease process.

Initiate seizure precautions for any child at risk.
■ Pad side rails of bed, crib, and wheelchair.
■ Keep bed free of objects that could cause injury.
■ Have suction and oxygen equipment available.
◯ During a seizure
■ Protect from injury (move furniture away, hold head in lap if on the floor).
■ Maintain a position to provide a patent airway.
■ Be prepared to suction oral secretions.
■ Turn client to the side (decreases risk of aspiration).
■ Loosen restrictive clothing.
■ Do not attempt to restrain the child.
■ Do not attempt to open the jaw or insert an airway during seizure activity (this may damage
teeth, lips, or tongue). Do not use padded tongue blades.
■ Remove glasses.
■ Administer oxygen.
■ Remain with the child.
■ Note onset, time, and characteristics of seizure.
■ Allow the seizure to end spontaneously.

◯ Postseizure
■ Maintain in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions.
■ Check vital signs.
■ Assess for injuries, including the mouth (tongue, teeth).
■ Perform neurologic checks.
■ Allow for rest if necessary.
■ Reorient and calm the client (due to agitation or confusion).
■ Maintain seizure precautions, including placing the bed in the lowest position and padding the
side rails to prevent future injury.
■ Note the time of the postictal period.
■ Remain with the client.
■ Do not offer food or liquids until completely awake and swallow reflex is present.
■ Encourage client to describe the period before, during, and after the seizure activity.
■ Determine if the client experienced an aura, which may indicate the origin of seizure in
the brain.
■ Try to determine the possible trigger, such as fatigue or stress.
■ Document the onset and duration of seizure and client findings/observations prior to, during,
and following the seizure (level of consciousness, apnea, cyanosis, motor activity, incontinence).

Myoclonic seizure
☐ Variety of seizure episodes
☐ Symmetric or asymmetric involvement
☐ Brief contractions of muscle or groups of muscle
☐ No postictal state
☐ May or may not lose consciousness

Atonic or akinetic seizure
☐ Muscle tone is lost for a few seconds.
☐ A period of confusion follows.
☐ Loss of muscle tone frequently results in falling.

◯ Infantile Spasms
■ Most common during first 8 months of life
■ Sudden, brief, symmetric muscle contractions
■ Flexed head, extended arms with legs drawn up
■ Possible eyes rolling upward and inward
■ Possible loss of consciousness
■ Possible flushing, pallor or cyanosis
■ Possible cry or giggle before or after

Simple partial seizures with motor signs
☐ Aversive seizure: eyes and head turn away from the side of focus, with or without loss of
consciousness
☐ Rolandic seizure: tonic-clonic movements involving the face and most common
during sleep
■ Simple partial seizure with sensory signs
☐ Tingling, numbness or pain in one area of the body then spreading to other parts, with
visual sensations.
■ Complex partial seizures
☐ Altered behavior
☐ Inability to respond to the environment
☐ Impaired consciousness
☐ Confusion and unable to recall event
☐ Complex sensory aura: strange feeling in stomach that rises to the throat, auditory or visual hallucinations, feelings of fear, distorted sense of time and self

Concussion is a injury to the brain that alters the way the brain functions.
● Contusion is bruising of the cerebral tissue.
● Laceration is tearing of the cerebral tissue.
● Fractures can be linear, depressed, comminuted, basilar, open, or growing.

Loss of consciousness - The length of time the client is unconscious is significant.
■ Minor Injury
☐ Possible loss of consciousness
☐ Confusion
☐ Vomiting
CHAPTER 14 Head Injury
130 RN Nursing Care of Children
☐ Pallor
☐ Irritability
☐ Drowsiness
■ Progression of Injury
☐ Changes in vital signs
☐ Altered mental status
■ Severe Injury
☐ Increased intracranial pressure (ICP)
--Infants: bulging fontanel, separation of cranial sutures, irritability, increased sleeping,
high-pitched cry, poor feeding, setting-sun sign
--Children: nausea, headache, vomiting, blurred vision, increased sleeping, inability to
follow simple commands, seizures

--Late Signs: alterations in pupillary response, posturing (decorticate and decerebrate),
bradycardia, decreased motor response, decreased sensory response, Cheyne-Stokes
respirations, coma

--Decorticate (dysfunction of the cerebral cortex) - Demonstrates the arms, wrists, and
fingers flexed and bent inward onto the chest and the legs extended and adducted.

--Decerebrate (dysfunction at the midbrain) - Demonstrates a backward arching of the
head and arms with legs rigidly extended and toes pointing downward.

◯ Corticosteroids - dexamethasone (Decadron) and methylprednisolone (Solu-Medrol) - used to
decrease cerebral edema
◯ Mannitol (Osmitrol) - osmotic diuretic used to treat cerebral edema
◯ Antiepileptics - used to prevent or treat seizures that may occur
◯ Antibiotics - in cases of CSF leakage, lacerations, or penetrating injuries

Epidural Hemorrhage
◯ Bleeding between the dura and the skull
◯ Clinical manifestations: short period of unconsciousness followed by a normal period leading to
herniation, coma, and death
● Subdural Hemorrhage
◯ Bleeding between the dura and the arachnoid membrane
◯ May be a result of birth injury, falls or violent shaking
◯ Clinical manifestations: irritability, vomiting, seizures
● Cerebral Edema
◯ Can develop within 24 to 72 hr posttrauma
◯ Clinical manifestations: increased ICP
● Brain Herniation
◯ Downward shift of brain tissue
◯ Clinical manifestations: loss of blinking, loss of gag reflex, pupils fail to react to light, coma, and
respiratory arrest

› Oxygen hood -small plastic hood that fits
over the infant's head
› Use a minimum flow rate of 4 to 5 L/min to prevent carbon dioxide buildup.
› Ensure that neck, chin, or shoulders do not rub against the hood.
› Secure a pulse oximeter for continuous SaO2
monitoring.

› Nasal cannula - disposable plastic tube
with two prongs for insertion into the nostrils
that delivers an oxygenconcentrations of 24% to
40% FiO2 at a flow rate of 1 to 6 L/min
› Nasal cannulas are safe, easy to apply, and well tolerated.
› The child is able to eat, talk, and ambulate while wearing a cannula.
› Cannulas may be used by infants and older children who are cooperative.
› Assess the patency of the nares.
› Ensure that the prongs fit in the nares properly.
› A nasal cannula may cause skin breakdown and dry mucous membranes.
› Supply the child with a water-soluble gel if the nares are dry.
› Provide humidification for flow rates greater than 4 L/min.
› Prongs can become dislodged easily; therefore, monitor the child frequently.

Pediatric face mask - pediatric-size mask that
covers the nose and mouth
› Face masks require a snug fit and may not be tolerated.
› Used for supplying high oxygen flow rate or for children who are mouth breathers.

Early signs of hypoxemia (restlessness, tachypnea, tachycardia, decreased SaO2
levels, adventitious breath sounds, visualization of secretions, cyanosis, absence of spontaneous cough)

Infants between 3 and 6 months of age are at an increased risk due to the decrease of maternal
antibodies acquired at birth and the lack of antibody protection.
■ Viral infections are more common in toddlers and preschoolers. The incidence of these
infections decreases by age 5.

› Nasopharyngitis (common cold)
» Self-limiting virus that persists for 7 to 10 days
› Nasal inflammation, rhinorrhea, cough, dry throat, sneezing, and nasal qualities in voice
› Fever, decreased appetite, and irritability

› Bacterial tracheitis
» Infection of the lining of the trachea
› Thick, purulent drainage from the trachea that can obstruct the airway and cause respiratory distress
› Fever, croupy cough, stridor

Bronchitis (tracheobronchitis)
» Associated with an upper respiratory infection (URI) and inflammation of large airways
» Self-limiting and requires symptomatic relief
› Persistent cough as a result of inflammation
› Resolves in 5 to 10 days

› Bronchiolitis
» Mostly caused by RSV
» Primarily affects the bronchi and bronchioles
» Occurs at the bronchiolar level
› Rhinorrhea - intermittent fever, cough, and wheezing
› Coughing that progresses toward wheezing, increased respiratory rate, nasal flaring, retractions, and cyanosis
› Possible posttussive vomiting due to coughing

› Allergic rhinitis
» Caused by seasonal reaction to allergens most often in the autumn or spring
› Watery rhinorrhea; nasal congestion; itchiness of the nose, eyes, and pharynx; itchy, watery eyes; nasal quality of the voice; dry,
scratchy throat; snoring; poor sleep leading to poor performance in school; and fatigue

☐ Elevated serum antistreptolysin-O (ASO) titer
☐ Elevated C-reactive protein (CRP) or sedimentation rate in response to an inflammatory reaction

› Pneumonia (RSV, Streptococcus
pneumoniae, Haemophilus
influenzae, Mycoplasma pneumoniae)
› High fever
› Cough that may be unproductive or productive of white sputum
› Retractions and nasal flaring
› Rapid, shallow respirations
› Report of chest pain
› Adventitious breath sounds (rhonchi, crackles)
› Pale color that progresses to cyanosis
› Irritability, anxiety, agitation, and fatigue
› Abdominal pain, diarrhea, lack of appetite, and vomiting
› Sudden onset, usually following a viral infection (bacterial pneumonia)

› Bacterial epiglottitis
(acute supraglottitis)
» Medical emergency
» Caused by Haemophilus influenzae
› Predictive signs - absence of cough, drooling, and agitation
› Sitting with chin pointing out, mouth opened, and tongue protruding
› Dysphonia (hoarseness or difficulty speaking)
› Dysphagia (difficulty swallowing)
› Inspiratory stridor (noisy inspirations)
› Sore throat, high fever, and restlessness

› Acute laryngotracheobronchitis
» Causative agents include
RSV, influenza A and B, and Mycoplasma pneumoniae
› Low-grade fever, restlessness, hoarseness, barky y cough, dyspnea, inspiratory stridor, and retractions

› Acute spasmodic laryngitis
» Self-limiting illness that may result from allergens
› Barky cough, restlessness, difficulty breathing, hoarseness, and nighttime episodes of laryngeal obstruction

Influenza A and B
» Mild, moderate, or severe
› Sudden onset of fever and chills
› Dry throat and nasal mucosa
› Dry cough
› Flushed face
› Photophobia
› Myalgia
› Fatigue

Pneumothorax - accumulation of air in the pleural space
◯ Clinical Manifestations - dyspnea, chest pain, back pain, labored respirations, decreased oxygen saturations, and tachycardia
◯ Nursing Interventions
■ Prepare client for an emergent needle aspiration with insertion of chest tube to closed drainage.
■ Provide for chest tube management.
■ Assess respiratory status.
■ Administer oxygen as prescribed

● Pleural effusion - accumulation of fluid in the pleural space
◯ Clinical manifestations - dyspnea, chest pain, back pain, labored respirations, decreased oxygen saturations, and tachycardia
◯ Nursing Interventions
■ Prepare the client for an emergent needle aspiration with insertion of chest tube to closed drainage.
■ Provide for chest tube management.
■ Assess respiratory status.
■ Administer oxygen as prescribed

Cystic fibrosis is a respiratory disorder that results from inheriting a mutated gene. It is characterized by:
◯ Mucus glands that secrete an increase in the quantity of thick, tenacious mucus, which leads to mechanical obstruction of organs (pancreas, lungs, liver, small intestine, and reproductive system).
◯ An increase in organic and enzymatic constituents in the saliva.
◯ An increase in the sodium and chloride content of sweat.
◯ Central nervous system abnormalities.

Meconium ileus at birth manifested as distention of the abdomen, vomiting, and inability to pass stool
■ Respiratory findings
☐ Early signs
X Wheezing
X Dry, nonproductive cough

☐ Increased involvement
X Dyspnea
X Paroxysmal cough
X Mucus plugs and atelectasis on x-ray

☐ Advanced involvement
X Cyanosis
X Barrel-shaped chest
X Clubbing of fingers and toes
X Multiple episodes of bronchitis or bronchopneumonia

■ Gastrointestinal findings
☐ Large, loose, fatty, sticky, foul-smelling stools
☐ Voracious appetite (early), loss of appetite (late)
☐ Failure to gain weight or weight loss
☐ Delayed growth patterns
☐ Distended abdomen
☐ Thin arms and legs
☐ Deficiency of fat-soluble vitamins
☐ Anemia
■ Integumentary findings
☐ Sweat, tears, and saliva are abnormally salty
■ Endocrine and reproductive system findings
☐ Viscous cervical mucus
☐ Decreased or absent sperm

■ To diagnose cystic fibrosis
☐ Sweat chloride test

Respiratory Complications
◯ Respiratory infections, respiratory colonizations, bronchial cysts, emphysema, pneumothorax, nasal polyps
● Gastrointestinal complications
◯ Meconium ileus, prolapse of the rectum, distal intestinal obstruction syndrome, GERD
● Endocrine complications
◯ Diabetes mellitus

› Coarctation of the aorta - a narrowing of the
lumen of the aorta, usually at or near the ductus
arteriosus, that results in obstruction of blood flowfrom the ventricle
› Elevated blood pressure in the arms
› Bounding pulses in the upper extremities
› Decreased blood pressure in the lower extremities
› Cool skin of lower extremities
› Weak or absent femoral pulses
› Heart failure in infants
› Dizziness, headaches, fainting, or nosebleeds in older children

› Transposition of the great arteries - a condition in which the aorta is connected to the right ventricle instead of the left, and the pulmonary artery is connected to the left ventricle instead of the right a septal defect or a PDA must exist in order to oxygenate the blood
› Murmur depending on presence of
associated defects
› Severe to less cyanosis depending on the size ofthe associated defect
› Cardiomegaly
› Heart failure

› Tricuspid atresia - A complete closure of the
tricuspid valve that results in mixed blood flow. An atrial septal opening needs to be present to allow blood to enter the left atrium.
› Infants - cyanosis, dyspnea, tachycardia
› Older children - hypoxemia, clubbing of fingers

› Tetralogy of Fallot - four defects that result in
mixed blood flow
» Pulmonary stenosis
» Ventricular septal defect
» Overriding aorta
» Right ventricular hypertrophy
› Cyanosis at birth - progressive cyanosis over thefirst year of life
› Systolic murmur
› Episodes of acute cyanosis and hypoxia (blue spells)

› Truncus arteriosus - failure of septum formation,resulting in a single vessel that comes off of the ventricles
› Heart failure
› Murmur
› Variable cyanosis
› Delayed growth
› Lethargy
› Fatigue
› Poor feeding habits

› Hypoplastic left heart syndrome - Left side of
the heart is underdeveloped. An ASD or patent
foramen ovale allows for oxygenation of the blood.
› Mild cyanosis
› Heart failure
› Lethargy
› Cold hands and feet
› Once PDA closes, progression of cyanosis and
decreased cardiac output result in eventual
cardiac collapse

◯ Manifestations of heart failure (HF)
■ Impaired myocardial function
☐ Sweating, tachycardia, fatigue, pallor, cool extremities with weak pulses, hypotension, gallop
rhythm, cardiomegaly
■ Pulmonary congestion
☐ Tachypnea, dyspnea, retractions, nasal flaring, grunting, wheezing, cyanosis, cough,
orthopnea, exercise intolerance
■ Systemic venous congestion
☐ Hepatomegaly, peripheral edema, ascites, neck vein distention, periorbital edema, weight gain
◯ Manifestations of hypoxemia
■ Cyanosis, poor weight gain, tachypnea, dyspnea, clubbing, polycythemia

■ Hypercyanotic spells (blue, or "Tet," spells) manifest as acute cyanosis and hyperpnea.

Digoxin (Lanoxin) - improves myocardial contractility
Captopril (Capoten) or enalapril (Vasotec)
◯ Metoprolol or carvedilol (Coreg) - beta-blockers, which decrease heart rate and blood pressure, and promote vasodilation
Furosemide (Lasix) or chlorothiazide (Diuril) - Potassium-wasting diuretics rid the body of excess fluid and sodium.

Rheumatic fever is an inflammatory disease that occurs as a reaction to Group A β-hemolytic
streptococcus (GABHS) infection of the throat.

Rheumatic fever usually occurs within 2 to 6 weeks following an untreated or partially treated upper respiratory infection (strep throat) with GABHS.

◯ History of recent upper respiratory infection
◯ Fever
◯ Tachycardia, cardiomegaly, prolonged PR interval, new or changed heart murmur, muffled heart sounds, pericardial friction rub, and report of chest pain, which may indicate carditis
◯ Nontender, subcutaneous nodules over bony prominence
◯ Large joints (knees, elbows, ankles, wrists, shoulders) with painful swelling, indicating polyarthritis
■ Findings may be present for a few days and then disappear without treatment, frequently
returning in another joint.
◯ Pink, nonpruritic macular rash on the trunk and inner surfaces of extremities that appears and disappears rapidly, indicating erythema marginatum
CNS involvement (chorea) including involuntary, purposeless muscle movements; muscle weakness; involuntary facial movements; difficulty performing fine motor activities; labile emotions; and random, uncoordinated movements of the extremities
◯ Irritability, poor concentration, and behavioral problems

Throat culture for GABHS
■ Serum antistreptolysin-O (ASO) titer - elevated or rising titer, most reliable diagnostic test
■ C-reactive protein (CRP) - elevated in response to an inflammatory reaction
■ Erythrocyte sedimentation rate - elevated in response to an inflammatory reaction

Major criteria
X Carditis
X Subcutaneous nodules
X Polyarthritis
X Rash (erythema marginatum)
X Chorea
☐ Minor criteria
X Fever
X Arthralgia

Vasoocclusive (painful episode)
› Usually lasts 4 to 6 days
› Acute
» Severe pain, usually in bones, joints, and abdomen
» Swollen joints, hands, and feet
» Anorexia, vomiting, and fever
» Hematuria
» Obstructive jaundice
» Visual disturbances
› Chronic
» Increased risk of respiratory infections and osteomyelitis
» Retinal detachment and blindness
» Systolic murmurs
» Renal failure and enuresis
» Liver cirrhosis; hepatomegaly
» Seizures
» Skeletal deformities; shoulder or hip avascular necrosis

Sequestration
Excessive pooling of blood primarily in the spleen (splenomegaly), and sometimes in the liver (hepatomegaly)
› Reduced circulating blood volume results in hypovolemia and can progress to shock
› Hypovolemic shock: irritability, tachycardia, pallor, decreased urinary output, tachypnea, cool extremities, thready pulse, hypotension

Aplastic
› Extreme anemia as a result of decreased RBC production
› Typically triggered by an infection

Hyperhemolytic
› Increased rate of RBC destruction leading to anemia, jaundice, and/or reticulocytosis

Hemophilia is a group of disorders characterized by difficulty controlling bleeding

Hemophilia A
› Deficiency of factor VIII
› Referred to as classic hemophilia
› Accounts for 80% of cases

Hemophilia B
› Deficiency of factor IX
› Referred to as Christmas disease

Episodes of bleeding, excessive bleeding, reports of joint pain and stiffness, impaired mobility, easy bruising, and activity intolerance

■ Active bleeding, which includes bleeding gums, epistaxis, hematuria, and/or tarry stools
■ Hematomas and/or bruising, even with minor injuries
■ Hemarthrosis as evidenced by joint pain, stiffness, warmth, swelling, redness, loss of range of motion, and deformities
■ Headache, slurred speech, and a decreased level of consciousness

■ Avoid taking temperature rectally.
■ Avoid unnecessary skin punctures and use surgical aseptic technique.
■ Apply pressure for 5 min after injections, venipuncture, or needle sticks

1-deamino-8-d-arginine vasopressin (DDAVP) is a synthetic form of vasopressin that increases
plasma factor VIII (antihemophilic factor [AHF])
■ Effective for mild, but not severe, hemophilia
■ Not effective for hemophilia B, which involves a factor IX deficiency

Factor VIII, products that contain factor VIII, pooled plasma, and recombinant products
■ Used to prevent and treat hemorrhage
■ Nursing Considerations - Administer by IV infusion

Diarrhea may be mild to severe, and acute or chronic. It may result in mild to severe dehydration.
◯◯ Acute diarrhea is a sudden increase in frequency and change in consistency of stool.
■■ It is usually secondary to an infectious agent in the GI tract, upper respiratory infection, urinary tract infection, antibiotic use, or laxative use.
■■ Self-resolution occurs in less than 14 days if dehydration does not occur.
◯◯ Acute infectious diarrhea is caused by a variety of viral, bacterial, or parasitic pathogens.
◯◯ Chronic diarrhea is an increase in frequency and change of consistency of stool(s) for more than 14 days.
■■ It is caused by chronic conditions such as malabsorption syndrome, food allergies, or
inflammatory bowel disease.
◯◯ Chronic nonspecific diarrhea has no identified cause.
●● Dehydration is a body fluid disturbance when the output exceeds intake. It results from many causes such as fluid losses through the skin, respiratory tract, urinary tract, or GI tract.

Hct, Hgb, BUN, creatinine, and urine-specific gravity levels are usually elevated with dehydration

A tape test should be performed to check for Enterobius vermicularis.

Review meds in chapter 22

(E. coli) - bacterial infection
››Watery diarrhea for 1 to 2 days, followed by
abdominal cramping and bloody diarrhea
›› Could lead to hemolytic uremic syndrome (HUS)
›› Transmission: depends on
strain of E. coli
›› Incubation period: 3 to 4 days

Salmonella- bacterial infection
››Mild to severe nausea, vomiting, abdominal
cramping, bloody diarrhea, and fever (may be
afebrile in infants)
›› Diarrhea may last as long as 2 to 3 weeks
›› Possible headache, confusion, drowsiness,
and seizures
››May lead to meningitis or septicemia
›› Transmission: person to person, undercooked meats and poultry
›› Incubation period: 6 to 72 hr

(C. difficile) - bacterial infection
››Mild, watery diarrhea for a few days
›› Possible less severe symptoms in children
than adults
›› Possible leukocytosis, hypoalbuminemia, and high fever in certain children
›› Possible pseudomembranous colitis
›› Transmission: contact with colonized spores, commonly in health care settings
›› Incubation period: nonspecified

(C. botulinum) - bacterial infection
›› Symptoms depend on strain
›› Abdominal pain, cramping, and diarrhea
›› Possible respiratory or CNS problems
›› Transmission: contaminated food products
›› Incubation period: 12 to 26 hr

Shigellosis - bacterial infection
›› Sick appearance
›› Fever, fatigue, and anorexia
›› Cramping abdomen followed by watery or
bloody diarrhea lasting 5 to 10 days
›› Transmission: contaminated food or water
›› Incubation period: 1 to 7 days

Caliciviruses - viral infection
›› Abdominal cramps, nausea and vomiting,
malaise, watery diarrhea
›› Lasts 2 to 3 days
›› Transmission: contaminated water
›› Incubation period: 12 to 48 hr

Staphylococcus - bacterial infection
›› Diarrhea, nausea, and vomiting ›› Transmission: inadequately cooked or refrigerated food
›› Incubation period: 1 to 8 hr

Enterobius vermicularis (pinworm) -
helminthic infection
›› Perianal itching, enuresis, sleeplessness,
restlessness, and irritability due to itching
›› Transmission: fecal-oral
›› Ingested or inhaled eggs hatch in the upper intestine, and mature. After mating, worms migrate out of the intestine
and lay eggs. Eggs can survive for 2 to 3 weeks on surfaces

Giardia lamblia - parasitic pathogen
›› Children 5 years of age or younger
»»Diarrhea
»»Vomiting
»»Anorexia
››Older children
»»Abdominal cramps
»»Intermittent loose, malodorous, pale,
greasy stools
›› Transmission: person to person, food, animals
›› The nonmotile stage of protozoa may survive in the environment for months.

Gastroesophageal reflux (GER) occurs when the gastric contents reflux back up into the esophagus,making esophageal mucosa vulnerable to injury from gastric acid and resulting in gastroesophageal
reflux disease (GERD).

Infants
■■ Excessive spitting up or forceful vomiting, irritability, excessive crying, blood in stool or
vomitus, arching of back, stiffening
■■ Respiratory problems
■■ Failure to thrive
■■ Apnea
◯◯ Children
■■ Heartburn, abdominal pain, difficulty swallowing, chronic cough, chest pain

Offer small, frequent meals.
■■ Thicken infants formula with 1 tsp to 1 tbsp rice cereal per 1 oz formula.
■■ Avoid foods that cause reflux (caffeine, citrus, peppermint, spicy or fried foods).
■■ Assist with weight control.
■■ Position the child with the head elevated at 30° for 1 hr after meals.

Hypertrophic pyloric stenosis is the thickening of the pyloric sphincter, which creates an obstruction.

Vomiting that often occurs following a feeding, but can occur up to several hours following a feeding and becomes projectile as obstruction worsens
Blood-tinged vomit
Constant hunger
Olive-shaped mass in the right upper quadrant of the abdomen and possible peristaltic wave thatmoves from left to right when lying supine
Failure to gain weight and signs of dehydration, such as skin that is dry and/or pale, cool lips, dry mucous membranes, decreased skin turgor, diminished urinary output, concentrated urine, thirst,
rapid pulse, sunken eyes

Start clear liquids 4 to 6 hr after surgery. Advance to breast milk or formula as tolerated.

Traction care - Traction, countertraction, and friction are used to align, immobilize, and reduce muscle spasms associated with certain fractures. Through the use of a forward-pulling force and a backward force, adding or removing weight controls the degree of force applied to maintain traction and alignment. The type of traction used depends on the fracture, age of the client, and associated injuries.
■ Skin traction uses a pulling force that is applied by weights (may be used intermittently). Using tape and straps applied to the skin along with boots and/or cuffs, weights are attached by a rope to the extremity (Buck, Russell, Bryant traction).
■ Skeletal traction uses a continuous pulling force that is applied directly to the skeletal structure and/or specific bone. A pin or rod is inserted through or into the bone. Force is applied through the use of weights attached by rope. Skeletal traction (90°/90° traction) allows the client to change positions without interfering with the pull of the traction and decreases complications associated with immobility and traction.
■ Balanced suspension traction suspends the leg in a flexed position. The hip and hamstring muscles are relaxed
---Halo traction (cervical traction) uses a halo-type bar that encircles the head. Screws are inserted into the outer table of the skull. The halo is attached to either bed traction or rods that are secured to a vest worn by the client

Cerebral palsy (CP) is a nonprogressive impairment of motor function, especially that of muscle control, coordination, and posture.

■ Failure to meet developmental milestones
■ Persistent primitive reflexes (Moro or tonic neck)
■ Gagging or choking with feeding, poor suck reflex
■ Tongue thrust
■ Poor head control ■ Rigid posture and extremities, abnormal posturing
■ Asymmetric crawl ■ Hyperreflexia ■ Vision or hearing impairments ■ Seizures ■ Impaired social relationships

Spastic (Pyramidal)
Hypertonicity (muscle tightness or spasticity); increased deep tendon reflexes; clonus; and poor control of motion, balance, and posture.
Impairments of fine and gross motor skills.
May present in all extremities (quadriplegia), similar parts of the body (diplegia), three limbs (triplegia), one limb (monoplegia), or one side of the body (hemiplegia); often causes affected limbs to be shorter and thinner.
Gait may appear crouched with a scissoring motion of the legs with intoeing and use of primarily the balls of the feet in a tip-toe fashion.
☐ Dyskinetic (Nonspastic, Extrapyramidal) Athetoid: Findings include involuntary jerking movements that appear slow, writhing, and wormlike. These movements involve the trunk, neck, face, and tongue.
Dystonic: Slow, twisting movements affect the trunk and extremities with abnormal posturing from muscle contractions.
☐ Ataxic (Nonspastic, Extrapyramidal)
Evidence of wide-based gait and difficulty with coordination
Poor ability to do repetitive movements Difficulty with quick or precise movements (writing or buttoning a shirt)
Shakiness--Low muscle tone

Baclofen (Lioresal) ■ Used as a centrally acting skeletal muscle relaxant that decreases muscle spasm and severe spasticity

Spinal bifida is failure of the osseous spine to close.
● Neural tube defects (NTDs) are present at birth and affect the CNS and osseous spine.
◯ Spina bifida occulta - Mostly affects the lumbosacral area and is not visible
◯ Spina bifida cystica - Has an visual sac protrusion
■ Meningocele - The sac contains spinal fluid and meninges.
■ Myelomeningocele - The sac includes meninges, spinal fluid, and nerves.

Physical Assessment Findings ■ Protruding sac midline of the osseous spine ■ Dimpling in the lumbosacral area

Closure of a myelomeningocele sac is done as soon as possible to prevent complications of injury and infection.

☐ Prepare the family for surgery (within the first 24 to 48 hr after birth).
☐ Protect the sac from injury.
☐ Place infant in a warmer, without clothing.
☐ Apply a sterile, moist, nonadhering dressing with 0.9% sodium chloride on the sac, changing it every 2 hr
Place infant in the prone position with hips flexed, legs abducted

Latex allergy ◯ The child may have a high risk of allergy to latex. Allergy responses range from urticaria to wheezing, which may progress to anaphylaxis. There also may be an allergy to certain foods (bananas, avocados, kiwi, and chestnuts).

Thermal, chemical, electrical, and radioactive agents can cause burns, which result in cellular destruction of the skin layers and underlying tissue. The type and severity of the burn impact the treatment plan.
◯ Thermal burns occur when there is exposure to flames, steam, or hot liquids.
◯ Chemical burns occur when there is exposure to a caustic agent. Cleaning agents used in the home (drain cleaner, bleach) and agents used in the industrial setting (caustic soda, sulfuric acid) cause chemical burns.
◯ Electrical burns occur when an electrical current passes through the body. This type of burn may result in severe damage, including loss of organ function, tissue destruction with the subsequent need for amputation of a limb, and cardiac and/or respiratory arrest

Review Page 375 Treatments for burns

› Superficial (first-degree) » Damage to epidermis
› Pink to red in color with no blisters, mild edema, and no eschar
› Blanches with pressure
› Painful. › Heals within 5 to 10 days.
› No scarring

› Superficial partial thickness (second-degree) » Damage to the entire epidermis
» Dermal elements are intact
› Pink to red in color with blisters, mild to moderate edema, and no eschar
› Blanches with pressure
› Pain is present. › Heals within 14 to 21 days.
› Variable amounts of scarring.
› Sensitive to temperature changes and light touch.

› Deep partial thickness (second-degree)
» Damage to the entire epidermis and some parts of the dermis » Sweat glands and hair follicles remain intact
› Red to white in color with blisters and moderate edema
› Blanches with pressure
› Pain is present.
› Sensitive to temperature changes and light touch.
› Healing time may extend beyond 21 days. › Scarring is likely.

› Full thickness (third-degree) » Damage to the entire epidermis and dermis and possible damage to the subcutaneous tissue » Nerve endings, hair follicles, and sweat glands are destroyed
› Red to tan, black, brown, or white in color › Dry, leathery appearance
› No blanching
› As burn heals, painful sensations return and severity of pain increases.
› Heals within weeks to months. › Scarring is present. › Grafting is required

› Deep full thickness (fourth-degree) » Damage to all layers of the skin that extends to muscle, tendons, and bones
› Color variable
› Dull and dry › Charring › Possible visible ligaments, bone or tendons
› No pain is present.
› Heals within weeks to months. › Scarring is present. › Grafting is required. › Amputation possible.

Wilms' tumor (nephroblastoma) is a malignancy that occurs in the kidneys or abdomen.
◯ The tumor is usually unilateral, with 10% of cases affecting both kidneys.
◯ Diagnosis typically occurs at an age younger than 5, with the majority of cases being diagnosed at about age 3. ◯ Metastasis is rare.

● Neuroblastoma is a malignancy that occurs in the adrenal gland, sympathetic chain of the retroperitoneal area, head, neck, pelvis, or chest.
◯ Usually manifested during the toddler years, with 95% of cases prior to age 10.
◯ Half of all cases have metastasized before diagnosis.

Wilms' Tumor
■ Firm, nontender abdominal swelling or mass ■ Fatigue, malaise, weight loss ■ Fever ■ Hematuria ■ Hypertension ■ Signs and symptoms of metastasis include dyspnea, cough, and shortness of breath.

Neuroblastoma
■ Symptoms depend upon the location and stage of disease. ■ Half of children who have neuroblastoma have few symptoms.
■ Signs and symptoms of metastasis include an ill appearance, periorbital ecchymoses, proptosis, bone pain, and irritability.

If Wilms' tumor is suspected, do not palpate the abdomen

Malignant tumors in bone may originate from all tissues involved in bone growth, including osteoid matrix, blood vessels, and cartilage.
◯ Osteosarcoma usually occurs in the metaphysis of long bones, most often in the femur. Treatment frequently includes amputation or limb salvage procedure of the affected extremity as well as chemotherapy.
◯ Ewing's sarcoma (a primitive neuroectodermal tumor [PNET]) occurs in the shafts of long bones and of trunk bones. Treatment includes surgical biopsy, intensive radiation therapy to tumor site, and chemotherapy, but not amputation.

◯ Rhabdomyosarcoma originates in skeletal muscle in any part of the body, but it most commonly occurs in the head and neck, with the orbit of the eye frequently affected. Treatment consists of surgical biopsy, local radiation therapy, and chemotherapy, rather than radical surgical procedures

◯ Osteosarcoma peaks at age 15 during growth spurts and is more common in boys.
◯ Ewing's sarcoma occurs prior to 30 years of age and is more common in Caucasians.
◯ Rhabdomyosarcoma occurs in children of all ages (but more commonly in children younger than 5 years of age) and is more common in Caucasians

Review page 467 treatments

What are the expected physical assessment findings in a 6 month old infant ATI?

Which developmental milestones would the nurse expect when assessing a preschooler?

What developmental milestone does the nurse expect to see in a two month old baby?

Which growth and development assessments would the nurse include when conducting a health maintenance visit for a 15 month old toddler quizlet?