Midterm book review- study guide NR602

12 August 2024

602 Midterm Book Review/Study Guide

Week 1 - Key Chapters:

  • Chapter 14: Introduction to Health Promotion and Health Protection (pp. 161-163)
  • Chapter 20: Sleep (pp. 283-284)
  • Chapter 22: Immunizations (pp. 306-317)
  • Chapter 44: Common Pediatric Injuries and Toxic Exposures (pp. 919-933)

Nurse Practitioner Roles:

  • Pediatric Nurse Practitioner (PNP): Focuses on health promotion, protection, and disease prevention in children.
  • Primary Care Nurse Practitioner (PCNP): Manages well-child care, including prevention and management of common pediatric acute illnesses and childhood diseases.
  • Acute Care Nurse Practitioner (ACNP): Specializes in caring for children who are acutely, chronically, or critically ill. These patients may be unstable, experiencing life-threatening conditions, or medically fragile and technology-dependent.

Prevention Strategies:

  1. Primary Prevention: Aimed at preventing diseases before they are established by eliminating causes or increasing people’s resistance to illness. This includes two main strategies:
    • Health Promotion: Efforts such as encouraging lifestyle changes, proper nutrition, and maintaining safe environments.
    • Specific Protection: Actions targeted at specific diseases, like immunizations, anti-malarial prophylaxis, and environmental modifications (e.g., adding fluoride to water supplies).
  2. Secondary Prevention: Involves early diagnosis and prompt treatment to interrupt the progression of a disease. This often includes screening for early detection and initiating treatment early to reduce symptoms or prevent disease progression.
  3. Tertiary Care: Focuses on improving survival rates and quality of life for those already affected by disease. It includes:
    • Disability Limitation: Managing early symptoms to prevent further disability.
    • Rehabilitation: Managing later symptoms to enhance patient recovery and quality of life.
  4. Quaternary Care: Involves the use of highly specialized expertise and equipment for managing rare or complex medical conditions.

Immunizations

Barriers to Vaccination: Several factors contribute to vaccine hesitancy among parents. Common concerns include beliefs that vaccines are unsafe, may cause autism, could overload or weaken a child’s immune system, or might be traumatic for the child. Some parents may also perceive a lack of threat from the diseases that vaccines prevent, leading them to undervalue the importance of immunization. Additional barriers include poverty and a lack of education.

Strategies to Encourage Vaccination:

  • Acknowledge and Respect: It is crucial to recognize and respect the trusted relationship between the healthcare provider and the parent. This relationship is foundational in addressing vaccine hesitancy.
  • Communicate Commitment: Clearly express a strong, shared commitment with the parent to the health and well-being of their child. Reinforcing the mutual goal of protecting the child can help build trust.
  • Listen and Address Concerns: Take the time to listen to parents’ reasons for refusing or delaying vaccines. Understanding that not all vaccine-hesitant individuals have the same concerns allows for tailored communication that addresses specific issues.
  • Educate on Misconceptions: Be well-informed about common misconceptions and controversies surrounding vaccines, such as the debunked link between vaccines and autism. Be prepared to discuss these topics and provide evidence-based information (e.g., thimerosal-free vaccines).
  • Emphasize Vaccine Safety: Highlight the rigorous testing that vaccines undergo before licensure, as well as the ongoing safety surveillance programs after they are approved. Explain the severe consequences that can arise from not vaccinating.
  • Discuss Simultaneous Vaccination: Educate parents about the safety of administering multiple vaccines at once. Reassure them that a healthy child’s immune system can effectively manage exposure to 2000 to 6000 antigens daily through normal activities like playing, eating, and breathing. The number of antigens in vaccines is much lower, with the entire schedule containing around 150 antigens, which is minimal compared to daily exposures.

Live Vaccines:

Live vaccines contain an attenuated (weakened) form of a virus that induces immunity without causing the disease. These vaccines generally provide broader and longer-lasting immunity. A mild fever or rash is a common side effect, indicating that the immune system is responding appropriately.

  • Age Restrictions: Live vaccines should not be administered before a child is 1 year old. If two live vaccines are needed, they should be given on the same day, or a four-week interval must be maintained between them to ensure efficacy.
  • Pregnancy Precautions: Live vaccines should not be administered to pregnant women or within 28 days before pregnancy.
  • Immunocompromised Individuals: Extra caution is required when administering live vaccines to immunocompromised individuals. Recommendations for these patients vary depending on their specific condition.
  • Measles, Mumps, and Rubella (MMR) Vaccine: The MMR vaccine is a trivalent vaccine given in two doses, starting at 12 months of age. After the two doses, the efficacy of the MMR vaccine is approximately 98%.

Side Effects and Precautions:

  • Rash and High Fever: After receiving certain vaccines, such as the MMR vaccine, children may experience a rash and high fever 5 to 12 days post-vaccination. This is a normal response indicating the immune system is reacting to the vaccine.
  • Seizure Risk with Varicella Vaccine: When the varicella vaccine is administered as part of a quadrivalent vaccine, the risk of febrile seizures doubles. However, this risk can be minimized by giving the varicella vaccine at the same time as other vaccines, but in different injection sites.
  • Pregnancy Precautions: Live vaccines, including the varicella vaccine, should not be administered during pregnancy or within 28 days prior to becoming pregnant.

Vaccine-Specific Information:

  • Varicella Vaccine: Administered in two doses, the varicella vaccine is 98% effective after the second dose. Severe cases of chickenpox have become rare due to widespread vaccination.
  • Rotavirus Vaccine: Given in two doses, the rotavirus vaccine is effective but carries a small risk of intussusception, a condition where part of the intestine folds into itself. This vaccine is an exception to the general rule that live vaccines are not given before the age of 1 year.
  • Smallpox Vaccine: Smallpox has been eradicated, so this vaccine is no longer routinely administered.

Passive Immunization:

  • Overview: Passive immunization involves administering an exogenous antibody, such as immunoglobulin, to provide immediate protection against specific infections.
  • Respiratory Syncytial Virus (RSV) Prophylaxis:
    • Palivizumab (Synagis): This is the only product available in the U.S. for preventing RSV infection in infants at high risk for severe outcomes. It is a humanized monoclonal antibody administered intramuscularly (IM) in five monthly injections during the RSV season, usually from November to March or April. It has been shown to reduce RSV hospitalizations in high-risk infants by 39% to 82%.
    • Candidates for RSV Prophylaxis:
      • Preterm Infants: Infants born at 29 weeks of gestation or earlier during the RSV season, up to 12 months of age.
      • Chronic Lung Disease (CLD): Children born at or before 32 weeks of gestation who are under 2 years old and have chronic lung disease requiring treatment within 6 months of the RSV season onset. Prophylaxis can also be given to 2-year-olds with CLD of prematurity who need medical support within 6 months prior to the RSV season.
      • Congenital Heart Disease: Infants up to 12 months old with significant cyanotic or complicated congenital heart disease.
      • Neuromuscular Disorders or Congenital Anomalies: Infants up to 12 months old with conditions that impair the clearing of respiratory secretions.

Killed (Inactivated) Vaccines:

  • Overview: Killed or inactivated vaccines offer systemic protection by stimulating the production of immune globulin G (IgG) antibodies. However, they may not trigger local mucosal immunity (IgA antibodies), which could result in local colonization or infection during an epidemic.
  • Common Inactivated Vaccines: These include vaccines for diphtheria-tetanus-pertussis (DTaP), polio, Haemophilus influenzae type B (Hib), hepatitis A, hepatitis B, human papillomavirus (HPV), meningococcus, and pneumococcus.

Common Side Effects:

  • General Reactions: Common side effects from vaccines often include mild to moderate fever, local swelling, pain, and erythema (redness) at the injection site. These symptoms typically occur within the first 24 to 72 hours after vaccination and are seen with vaccines such as DTaP, tetanus-diphtheria (Td), tetanus-diphtheria-acellular pertussis (Tdap), Haemophilus influenzae type B (Hib) conjugate, hepatitis B virus (HBV), and pneumococcal conjugate (PCV-13).
  • Allergic Reactions: While uncommon, there is a concern for allergic reactions following vaccination. Healthcare providers should monitor for these reactions, especially after administering vaccines known to cause systemic reactions, such as Tdap, meningococcal, and HPV vaccines.
  • Syncope: Fainting (syncope) is a common reaction, particularly associated with the Tdap, meningococcal, and HPV vaccines. Other side effects of the meningococcal vaccine may include headache and irritability.

Vaccine-Specific Information:

  • Diphtheria-Tetanus-Acellular Pertussis Vaccine (DtAP): Administered in 4 doses to children under the age of 7. The pertussis component is not long-acting, necessitating multiple doses to maintain immunity.
  • Tdap Vaccine: This vaccine is given multiple times throughout life, including during pregnancy (recommended between 27-36 weeks gestation) and as a booster every 10 years in adults.
  • Polio Vaccine: The polio vaccine is available in an inactivated form in the U.S., administered in 4 doses. It is particularly recommended for immunocompromised individuals.
  • Haemophilus influenzae Type B (Hib) Vaccine: Given in 3 doses, the Hib vaccine has significantly reduced the incidence of infections like pneumonia, bacteremia, meningitis, and other serious conditions in children under age 4.
  • Hepatitis A Virus Vaccine: Administered in 1 to 2 doses, this vaccine offers protection for 14-20 years and is recommended for children under 18 months.
  • Hepatitis B Virus Vaccine: This vaccine is given in 3 doses, typically at birth, 1-2 months, and 6-18 months. Immunogenicity lasts up to 20 years, and routine booster doses are not generally recommended.
  • Human Papillomavirus (HPV) Vaccine: Administered in 2 doses 6 months apart to individuals aged 9-26. The vaccine is safe with mild side effects but should not be given to pregnant women.
  • Influenza Vaccine: Given yearly to individuals aged 6 months and older. Widespread vaccination helps achieve herd immunity, protecting those who are not immunized.
  • Meningococcal Vaccine: Administered in 2 doses, typically starting at age 11-12, with a booster at 16 years. The vaccine is crucial for preventing a disease with high morbidity and mortality, especially in late high school and college-age individuals.
  • Pneumococcal Vaccine: There are 91 known serotypes of pneumococcus. The PCV13 vaccine is given to children up to 59 months old, while the PCV23 vaccine is recommended for high-risk groups, including infants and the elderly.

Vaccine Schedule:

  • Birth: Hepatitis B (Hep B)
  • 2 Months: Hep B, Rotavirus, DTaP (Diphtheria, Tetanus, Acellular Pertussis), Hib (Haemophilus influenzae type B), PCV13 (Pneumococcal Conjugate), Polio (BDRHIP)
  • 4 Months: Rotavirus, DTaP, Hib, PCV13, Polio (DRHIP)
  • 6 Months: Hep B, DTaP, PCV13, Polio (BDRHIP again)
  • 12 Months: Hib, Influenza (Flu), MMR (Measles, Mumps, Rubella), Varicella (Chickenpox), Hepatitis A (Hep A)
  • 18 Months: (This interval typically includes a booster dose, but specifics vary based on the child’s vaccine history.)
  • Age 4-6 Years: MMR, Varicella, Polio, DTaP
  • Age 11-12 Years: Tdap (Tetanus, Diphtheria, Acellular Pertussis), Meningococcal, HPV (Human Papillomavirus)
  • Age 16 Years: Meningococcal

Vaccines for Children (VFC) Program:

The VFC program allows primary care providers to offer Advisory Committee on Immunization Practices (ACIP)-recommended vaccines at no cost. This program is available to children under 19 years old who are eligible for Medicaid, uninsured, or who are Native American or Alaska Native. Additionally, children without insurance coverage for immunizations can receive vaccines at Federally Qualified Health Centers (FQHCs) and rural health clinics. The VFC program plays a significant role in reducing vaccination disparities among low-income children.

Sudden Infant Death Syndrome (SIDS) Prevention:

Sudden Unexpected Infant Death (SUID): This term encompasses any sudden and unexplained death during infancy, which can result from suffocation, asphyxia, entrapment, infection, ingestion, metabolic diseases, or trauma, whether accidental or non-accidental.

SIDS: After thorough investigation, many SIDS cases are linked to suffocation or overheating, particularly in infants who sleep on their stomachs or with unsafe bedding. About 90% of SIDS cases occur before 6 months of age, with a higher likelihood among premature or growth-restricted infants.

Recommendations for SIDS Prevention:

  • Share a room with the baby but avoid bed-sharing.
  • Avoid substances that could impair judgment, such as alcohol or drugs, especially during pregnancy and after the baby is born.
  • Use a firm mattress without loose bedding or bumper pads.
  • Keep the baby’s sleeping area cool to prevent overheating.
  • Encourage breastfeeding and ensure the baby receives timely immunizations.
  • Educate parents on safe sleep practices.

Lead Poisoning:

Overview: Lead is a naturally occurring substance that can be toxic when ingested or inhaled, particularly in children. Lead poisoning often mimics iron deficiency anemia, as lead inhibits the binding of iron to hemoglobin. This condition cannot be corrected with iron supplements alone if lead toxicity is present.

Chelation Therapy: This treatment is recommended for children with blood lead levels above 45 micrograms per deciliter (mcg/dL).

Risk Factors for Lead Exposure:

  • Homes: Lead-based paint, commonly found in homes built before 1972, is a significant source of exposure. Chipped or peeling paint on antique furniture and toys also poses a risk.
  • Water: Plumbing soldered with lead or fixtures not intended for drinking water (e.g., hoses, spigots) can contaminate water with lead.
  • Soil/Yards/Playgrounds: Children can breathe in or swallow lead-contaminated soil while playing. Eating fruits and vegetables grown in contaminated soil also poses a risk. Additionally, old playground equipment may contain lead-based paint or other sources of contamination.

Additional Risk Factors for Lead Exposure:

  • Artificial Turf and Playground Surfaces: Playground surfaces made of shredded rubber and artificial turf can be potential sources of lead exposure.
  • Imported Goods: Certain imported goods pose a risk for lead exposure, including glazed pottery, spices from Asian, Hispanic, and Indian origins, Mexican candy containing tamarind and chili, toys, jewelry, and cosmetics.
  • Hobbies: Activities such as handling lead bullets, using lead sinkers for fishing, working with stained glass, and refurbishing antique furniture can increase exposure to lead.

Signs and Symptoms of Lead Poisoning:

  • The most common gastrointestinal (GI) symptoms include abdominal pain, stomach aches, and constipation.

Pediatric Injuries and Toxic Exposures:

Abrasions:

  • Description: Abrasions are superficial injuries resulting from epidermal trauma, often due to falls. These injuries involve the scraping off of skin, sometimes accompanied by oozing of serous fluid and/or blood.
  • Assessment: It’s crucial to thoroughly assess the injury for signs of increasing pain, swelling, warmth, erythema (redness), and red streaking, which may indicate deeper injury or secondary infection. Surrounding tissue should be evaluated for circulation, sensation, motion, and function.
  • Management: Most abrasions can be managed at home unless they are deep, involve a large area, are associated with severe pain, or contain significant dirt, grime, tar, or foreign objects. The wound should be cleansed by gently scrubbing with soap or an antibacterial cleanser using wet gauze or a soft surgical nail brush. However, the preferred method is gentle irrigation with copious amounts of water or normal saline (300 to 1000 mL depending on the wound’s surface area).

Puncture Wounds:

  • Classification: Puncture wounds can be classified as superficial or deep. Common sources include glass, wood splinters, toothpicks, needles, nails, metal, staples, thumbtacks, and animal bites.
  • Assessment: If there is suspicion of a retained foreign object, a plain film radiograph should be obtained. Ultrasound is particularly effective for evaluating radiolucent foreign objects, such as wood and plastic.

Antibiotics for Animal Bites:

  • General Guidance: Children with simple, uncomplicated puncture wounds generally do not need antibiotics. Exceptions include cases with signs of infection, cat bites, wounds to the hand, foot, or genitalia, punctures near a joint or bone, or deep wounds containing debris.

Oral Antibiotic Prophylaxis After Puncture Wounds:

  • Human Bites: First-line treatment is Amoxicillin-clavulanate for 7-10 days.
  • Animal Bites: First-line treatment is also Amoxicillin-clavulanate for 7-10 days.
  • Plantar Wounds: Ciprofloxacin is recommended for 7-20 days, depending on the severity of the wound.

Bites & Stings:

  • Infection Management: If a wound infection is suspected following a bite or sting, it is important to obtain both aerobic and anaerobic cultures, along with a Gram stain, before starting antibiotic therapy. This ensures accurate identification of the causative organisms and appropriate treatment.

Acute Pediatric Poisoning:

  • Overview: Poisoning occurs when a substance that interferes with normal body function is ingested, inhaled, absorbed, or injected. Acute poisoning refers to exposure that leads to immediate symptoms, while toxic environmental exposures tend to be chronic or insidious.
  • Prevention Recommendations from the American Association of Poison Control Centers (AAPCC) (2017):
    • Safe Storage: Store all potentially harmful substances out of children’s reach, out of sight, and in their original containers. This includes:
      • Medications and pharmaceuticals, including over-the-counter (OTC) medications, vitamins, and supplements.
      • Tobacco products, e-cigarettes, marijuana (cannabis) products, and alcohol.
      • Laundry and cleaning supplies.
      • Pesticides and insect repellents.
      • Button batteries.
      • Oils, lubricants, and other chemicals.
      • Personal care products, such as cosmetics, contact lens cleaners, and hand sanitizers.
  • Additional Safety Strategies:
    • Chemical Safety: Never mix cleaning chemicals and always follow label instructions when using cleaning products.
    • Insect Repellents: Apply insect repellent according to label instructions, avoiding the hands, and wash it off after returning indoors.
    • Invisible Threats: Be aware of and detect invisible threats like carbon monoxide, asbestos, and radon.
    • Medication Safety: Do not share medications and avoid using more than one medication with the same active ingredient.
    • Proper Disposal: Dispose of medications, especially narcotics, at a pharmacy as soon as they are no longer needed.
    • Smoking Cessation: Encourage caregivers who use tobacco, nicotine, or cannabis to quit.
    • Avoiding Toxic Plants: Avoid exposure to poisonous plants and mushrooms.
    • Food Safety: Store and prepare food safely to avoid contamination.
  • Common Causes of Pediatric Poisoning:
    • The leading causes of poisoning in children under 6 years old include cosmetics and personal care products, cleaning substances, and analgesics (pain relievers).
  • Addressing Emerging Poisoning Risks:
    • Primary Care Providers (PCPs) should be vigilant about the increasing incidence of poisonings related to laundry detergent packets/pods, analgesics (especially opioids), and marijuana (cannabis) products. Common analgesics involved include acetaminophen, ibuprofen, and aspirin.
  • In Case of Ingestion:
    • If a child ingests a potentially toxic substance or takes a supratherapeutic dose of medication (whether suspected or confirmed), consult the regional poison control center immediately for guidance on appropriate actions.
  • Intentional vs. Unintentional Poisoning in Adolescents:
  • Intentional Poisoning:
  • Adolescents are more likely to intentionally misuse over-the-counter (OTC) medications, prescribed medications, or chemicals/illicit drugs for recreational purposes. They are also at a higher risk of attempting or completing suicide using poisons, OTC medications, or prescription drugs, either intentionally or unintentionally.
  • Clinical Manifestations of Poisoning in Children (Box 44.2):
  • Heart Rate:
  • Manifestations can include bradycardia (slow heart rate) or tachycardia (fast heart rate).
  • Respirations: Respiratory effects may present as bradypnea (slow breathing) or tachypnea (fast breathing).
  • Blood Pressure: Poisoning can cause hypotension (low blood pressure) or hypertension (high blood pressure).
  • Temperature: Variations can include hypothermia (low body temperature) or hyperpyrexia (extremely high fever), which differs from hyperthermia.
  • Neurological Symptoms: These can include central nervous system (CNS) depression (which may progress to coma), agitation, delirium/psychosis, seizures, ataxia (lack of muscle coordination), weakness or paralysis, tremors/myoclonus, choreoathetosis (involuntary movements), and rigidity.
  • Ophthalmologic Symptoms: These may include miosis (constricted pupils), mydriasis (dilated pupils), and nystagmus (involuntary eye movement).
  • Dermatologic Signs: These can include jaundice (yellowing of the skin), cyanosis (bluish discoloration), and unusual skin colors like pink or red.
  • Odors: Certain poisons can cause distinctive odors, such as acetone (fruity smell), bitter almond, garlic, mothballs, oil of wintergreen, gasoline, turpentine, kerosene, or the smell of rotten eggs.
  • Week 2 - Key Chapters:
  • Chapters 9, 10, 11, 12, 13, 21, 32, 45
  • (pp. 945-9463)
  • Newborn Assessment (Including Eye Screenings):
  • Initial Screenings Post-Birth: These include checking for Rh(d) incompatibility, promoting breastfeeding, screening for sickle cell hemoglobinopathies to identify neonates at risk of sepsis, and testing for congenital hypothyroidism and phenylketonuria (PKU). Other screenings involve administering topical ocular prophylaxis to prevent ophthalmia neonatorum and checking for hip dysplasia.
  • Nutrition Assessment: Evaluate whether the newborn is receiving adequate nutrition. Colostrum typically comes in 2-5 days after birth. Alcohol and nicotine can pass into breast milk, reducing the milk supply. While most medications are safe during breastfeeding, only about 1% pass through to the baby. If a mother is on chronic medication, ensure it is safe for breastfeeding. If not, she may need to pump and discard her milk (“pump and dump”) for a few days.
  • HUNGRY Mnemonic for Assessing Newborns:
    • Hypoglycemia: Indicated by high-pitched crying, jitteriness, and potential seizures.
    • Unsatisfied Nursing: Nursing sessions shorter than 2 hours apart with continued hunger cues.
    • Not Waking Up: If the baby does not wake up to feed every 2 hours or has difficulty latching.
    • Growth Issues: Weight loss greater than 7% at any time.
    • Reduced Diapers: Fewer wet or soiled diapers than expected.
    • Yellowing of the Skin: This may indicate jaundice.
  • APGAR Score: Assessed at birth and 5 minutes after, evaluating Activity, Pulse, Grimace, Appearance, and Respiration.
  • Within 2 Hours of Birth: Perform a physical assessment, including measuring the newborn’s length, weight, and front-occipital circumference, which should be plotted on growth curves based on gestational age. Vital signs should be checked frequently in the first hours and then every 6-8 hours once stable.
  • Respiratory Assessment: Ensure that amniotic fluid has been expelled from the lungs.
  • Umbilical Cord Care: The umbilical cord should be clamped and left to air dry. It should normally have two arteries and one vein.
  • Initial Screenings: Conduct initial screenings as mentioned above and administer the first dose of the Hepatitis B vaccine.
  • Physical Assessment of the Newborn:
    • Vital Signs: Check vital signs frequently in the first hours after birth and every 6-8 hours once stable.
    • Temperature Stability: Monitor for temperature stability in an open crib (97.7°F–99.3°F [36.5°C–37.4°C]).
    • Respiratory Rate: Normal respiratory rate is between 30 to 60 breaths per minute.
    • Heart Rate: A normal heart rate ranges from 100 to 190 beats per minute.
    • Weight and Growth: Measure and plot the baseline weight, length, and head circumference. A daily weight loss of up to 10% in the first 2-3 days is normal.
  • Skin Examination: Normal findings may include lanugo (fine hair), vernix (a waxy coating), and dry or cracked skin.
  • Head Assessment: Newborns delivered vaginally may exhibit molding and overriding suture lines.
  • Fontanels: The anterior fontanel is typically about 2-3 cm in diameter, while the posterior fontanel is about 1 cm in diameter.
  • Face: Facial structures and grimaces should be symmetrical.