Study Guide Exam 2 NSG 213 - Pediatric Nursing | PDF

**Study Guide Exam 2 NSG 213** **[The Child with Gastrointestinal Dysfunction- Chapter 6,8,13,22]** [Fluid and Electrolyte Imbalances] - Sodium is the chief solute in ECF - Hyponatremia, hypernatremia - Potassium is found primarily in the cell (ICF) - Hypokalemia, hyperkalemia...

**Study Guide Exam 2 NSG 213** **[The Child with Gastrointestinal Dysfunction- Chapter 6,8,13,22]** [Fluid and Electrolyte Imbalances] - Sodium is the chief solute in ECF - Hyponatremia, hypernatremia - Potassium is found primarily in the cell (ICF) - Hypokalemia, hyperkalemia - Infants and young children have a greater need for water and are more vulnerable to alterations in F&E balance. [Dehydration (Volume Depletion)] - Total output \> total intake - Causes: - Reduced oral intake. - Vomiting - Diarrhea - DKA - Burns - ECF loss initially \> decreased blood volume and pressure - The compensatory mechanism moves ICF to ECF to conserve intravascular volume. - Always assess for impending shock [Therapeutic Management ] Mild to moderate Dehydration - Oral rehydration therapy - Child is awake, alert, and not in danger. - Pedialyte - Popsicles (avoid cherry or other red flavors) - Mild (50ml/kg) - Moderate (100ml/kg) Severe Dehydration - Iv fluid therapy - The child is unable to ingest enough fluid and electrolytes. - Usually, an isotonic solution such as 0.9 NS or LR solution - Initial therapy is 20ml/kg IV bolus over 5 to 20 minutes. [Signs of Dehydration] - Dry mouth - Sunken eyes - Dark urine - Urine output decreases - Fatigue - Drowsiness - Irritability - Skin turgor will stand up and not return for a few minutes. - Pitting edema [Diarrhea] - Symptom, not a disease - Causes: - Stomach and intestines (gastroenteritis) - Small intestine (enteritis) - Colon (colitis) - Colon and intestines (enterocolitis) [Acute] - Sudden onset - Often caused by an infectious agent in the GI tract - Rotavirus is the most common cause in children \< 5 years old. - **Don't** give anti-diarrheal if they have rotavirus. - Self-limited (\< or equal to 14 days duration) - Persistent episodes can cause dehydration (particularly \ 14 days - Caused by chronic conditions such as malabsorption syndromes, inflammatory bowel disease, food intolerances, nonspecific factors, etc. [Constipation] - Infrequent and difficult passage of dry, hardened stool - Symptom, not a disease - The majority of children have idiopathic (functional) constipation - Age-specific consideration - Newborn period -- first meconium should be passed within 24-36H - Infancy -- often related to diet - Childhood -- changes/control over body functions or stress - Encopresis is constipation with fecal incontinence - Management involves high fiber diet, adequate fluid intake, exercise, bowel training, stool softeners/laxatives/enemas - May not have enough fiber in your diet [Vomiting (Emesis)] - Coordinated process involving expulsion of stomach contents - Vomiting ≠ regurgitation - If persistent or severe, major concerns are dehydration, electrolyte disturbances, [metabolic alkalosis,] and aspiration - Management directed towards identifying cause and preventing complications - It can indicate stenosis or increased intracranial pressure if projectile vomiting. - Sunken fontanel - Dry mucous membranes - Decrease in urinary output - Educate when to let the provider know - Abd pain [Hirschsprung Disease (Congenital Aganglionic Megacolon)] - Congenital anomaly affecting 1 in 5000 births. - More common in males and in Down syndrome - Absence of ganglion cells in an area of the colon (large intestine) - Mechanical obstruction from inadequate motility of intestine - Internal sphincter does not relax - Hirschsprung-associated enterocolitis (HAEC) - A rectal biopsy (confirmative) - Relieving constipation - Stool softeners - Rectal irrigation - Low-fiber, high-calorie, high-protein diet 1. Temporary colostomy 2. "Pull-through" procedure. - Strict I&Os - Obtain weight and measure abdominal girth daily - Maintain NPO status until bowel sounds return or flatus is passed, usually within 48 to 72H - Maintain nasogastric tube to allow intermittent suction until peristalsis returns - Maintain IV fluids until the child tolerates appropriate oral intake, advancing the diet from clear liquids to regular as tolerated - Assess surgical site and stoma for bleeding or skin breakdown - Monitor VS, avoid rectal temperatures - Provide the parents with instructions regarding colostomy care and skin care - Teach the parents about the appropriate diet and the need for adequate fluid intake [Inflammatory Bowel Disease] 1. Crohn's disease (CD) 2. Ulcerative colitis (UC) 3. Inflammatory bowel disease unspecified (IBDU) - No known cause and etiology not completely understood - UC limited to colon and rectum - CD can involve any part of the GI tract from mouth to anus; most often terminal ileum - Pediatric onset tends to be more aggressive [Clinical Manifestations:] - UC with insidious onset of diarrhea, hematochezia, without fever or weight loss - CD with diarrhea, cramping abdominal pain, fever, and weight loss - Growth failure present before GI symptoms (CD \> UC) - Exacerbations and remissions are characteristic - Inflammation or destruction of the bowel wall can cause permanent damage - IBD is normally very aggressive, it usually have flareups without completely having remission - Sometimes treated w/ steroids [Irritable Bowel Syndrome (IBS)] - Classified as a functional GI disorder - Occurs more frequently in adolescents, than children - Increased GI motility causing spasms and pain - Alternating diarrhea and constipation w/ mucous in stools - Recurrent abdominal pain unrelated to meals or activity - Etiology unclear -- Genetic and environmental factors - Diagnosis is based on the elimination of other causes - Syndrome is a self-limiting, intermittent issue, with no definitive treatment - Management involves controlling symptoms [Therapeutic Management] - Constipation predominant - increase fiber with diet changes - Diarrhea predominant -- diet changes, PPIs, loperamide - Probiotics may be effective - Anticholinergics (hyoscyamine and dicyclomine) daily or PRN - CBT for stress management - Antidepressants with severe psychosocial symptoms [Nursing Care Management:] - Family support and education - Reassurance - Inform parents about psychosocial resources, if needed - Encourage a well-balanced, moderate-fiber, low-fat diet - Encourage health promotion activities (e.g., exercise, school) [Gastroesophageal Reflux (GERD)] - Transfer of gastric contents into the esophagus - Inappropriate, transient relaxation of lower esophageal sphincter (LES) - Occurs throughout the day; most frequently after meals and at night - GERD represents symptoms or tissue damage, and becomes a disease when complications like FTT, respiratory issues, or dysphagia develop - The peak incidence of GER occurs at 4mos, and resolves by 1 yoa - Most common symptom in infancy is passive regurgitation - Regurgitation resolves in most by 12 mos, almost all by 24 mos - DX: HX, PE, Upper GI series, Endoscopy w/biopsy (severe) [Therapeutic Management of GER/GERD] - Assess characteristics of vomiting - Assess breath sounds, for signs of aspiration - Supine sleeping in infants - Pharmacologic interventions - H2 blockers (ranitidine, famotidine) - PPI (esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole) - Surgical intervention---Nissen fundoplication - Probably won't see reglan in infants, was for GERD but don't use anymore - Elevate the head of the bed - Feeding alterations - Small, frequent feedings - Frequent burping when feeding - Thickening feedings - Upright positioning - Avoid overfeeding - Solids first, followed by liquids - Avoid rigorous play/activity - Weight loss, in some cases - Avoid offending foods [Acute Appendicitis] - Inflammation of vermiform appendix - Peak incidence 12-18 yrs - Caused by obstruction of the lumen of the appendix by a fecalith (common) - Swollen lymph after viral infection - Parasitic obstruction - Obstruction \> pressure builds in lumen \> ischemia \> ulceration of lining \> bacterial invasion \> necrosis \> perforation (rupture) \> peritonitis \> sepsis \> shock \> death - Prolonged symptoms, delayed diagnosis and rupture common in younger children - Perforation (rupture) of the appendix can occur within 48H of pain onset - Usually, sudden relief of pain after rupture, then increase in pain - S/S Peritonitis: fever, chills, diffuse pain, rigid abdomen, guarding, progressive abdominal distention, tachycardia, tachypnea, pallor, irritability, restlessness - Other complications from rupture -- phlegmon, abscess, fistula, partial bowel obstruction [PREOPERATIVELY] - Maintain NPO status - IV fluids, antibiotics - Monitor for S/S peritonitis - Monitor bowel sounds - Monitor for changes in pain - Avoid use of pain medications - Apply ice packs, avoid heat - Right side or Semi-Fowler's - Avoid laxatives or enemas [POSTOPERATIVELY] - Monitor VS, especially temp - IV fluids, analgesics, antibiotics - Maintain NPO status - Maintain NG tube/suctioning - Resume diet slowly - Assess incision site for infection - Change dressings - Right side or Semi-Fowler's with legs slightly flexed  - McBurney's Point- most common site of maximum tenderness in acute appendicitis, which is typically determined by the pressure of one finger. - Rosing sign- tenderness in RLQ in palpation in other quadrants - Obturator sign\-\-- ASK Jenny, plain w flexion and rotation of the right hip - Psoas-Pain on left side w right hip extension - Referred pain- peritoneal irritation - WBC is always elevated in appendicitis [Intussusception] - Telescoping (or invagination) of one portion of the intestine into another - Results in partial/complete obstruction to the passage of intestinal contents - More common in males and children ≤ 2 years - Etiology unknown---often follows viral illness - Occasionally due to intestinal lesions - Classic presentation---"currant jelly--like stools" - Caused from leaking blood and mucous into intestinal lumen - Most common site is the ileocecal valve (ileocolic) - Necrosis- can lead to infection or death of bowel tissue - A most common cause of intestinal dysfunction in children less than 2 yo, but can happen up to six years old [Classic triad of symptoms] - Sudden onset of abdominal pain with child appearing normal and comfortable between episodes - Abdominal mass "sausage-like" known as 'Sign De Dance' - Currant jelly--like stools - Drawing knees up, pain is severe - Pushed back in younger children called a 'reduction' - Older children it will need surgery [Diagnostic Evaluation:] - History and physical exam - Rectal exam - Abdominal ultrasound (definitive) - "bull's eye" [Therapeutic Management: ] - Attempt conservative treatment (nonsurgical) first - Gas enema (pneumoenema) - Radiologist guided - With or without contrast - Hydrostatic (saline) enema - Ultrasound-guided - If unsuccessful, progress to surgery - Surgical reduction and fixation, and/or - Excision of nonviable segment of colon [Nursing care:] - Monitor for signs of shock - Antibiotics, IV fluids - NG tube decompression - Prepare client and parent for procedure/surgery - Monitor for bowel sounds - Monitor for normal stool - Post-op care [Celiac Disease] - Also called gluten-induced enteropathy and celiac sprue - Malabsorption syndrome is characterized by malabsorption of nutrients and diarrhea, which may result in FTT -- failure to thrive - Intolerance to gluten, the protein component of wheat, barley, rye, and oats - Usually occurs 3-6 months after introduction to gluten in diet - Diagnosis by blood test for IgA antibodies (tTG-IgA test) [Clinical Manifestations:] - Vomiting and Diarrhea - Steatorrhea - Abdominal pain and distention - Anorexia with malnutrition and vitamin deficiencies and muscle wasting - Symptoms most often occur between 1-5 yoa - Dietary management eliminating gluten with adherence to regimen throughout lifetime - Vitamin supplementation -- iron [What to Avoid:] - Ice cream - Malted milk - Barley - Rolls, cakes, macaroni noodles, prepared puddings [Hepatitis] - Acute or chronic inflammation of the liver (vital organ) - Infectious and noninfectious - Types: Hepatitis A, B, C, D, E - Table 22.8, p. 718 - Treatment aimed at resting the inflamed liver to reduce demands and increase the blood supply, promote cellular regeneration, and prevent other complications. 1. [Anicteric (Prodromal) Phase] - Anorexia (loss of appetite) - Fever - N/V/D - RUQ abdominal pain - Hepatomegaly - Arthralgia (HBV) - Pruritic rash (HBV) 2. [Icteric Phase] a. Jaundice b. Light or clay-colored stools c. Dark urine 3. [Recovery Phase] d. Fatigue [Hepatitis A Virus (HAV)] - Highest incidence in preschool & school-age children \< 15 yrs - Transmission via fecal-oral route (primarily) - S/S: acute onset; asymptomatic (especially infants) to mild N/V/D - Can be asymptomatic and still spread infection - **Light-colored stools w or w/o jaundice, if asymptomatic, they can still spread the infection** - Prevention: Hepatitis A vaccine [Hepatitis B Virus (HBV)] - Found in all bodily fluids - Blood, semen, and saliva are infectious - Breastfeeding is recommended in all infants\* - Perinatal transmission (primarily in children) - Specific high-risk groups - S/S: gradual onset, pruritic rash, arthralgia; jaundice possible - Severity ranges (mild/self-limiting \> fulminant/fatal) - Chronic infections lead to cirrhosis, liver cancer, and death - Active or inactive carrier [Hepatitis C Virus (HCV)] - Transmission: perinatal (primarily in children) 1. *Parenteral (illegal drug use)* 2. *Sexual* - S/S: gradual onset, variable; asymptomatic; chronic 3. Chronic infections can lead to cirrhosis, liver cancer, and death 4. Most common cause of chronic liver disease 5. Chronic or severe cases need direct-acting antiviral drugs and possibly a liver transplant - Carrier state - No vaccine available - PCR test they will do - Direct- acting antiviral drugs [Hepatitis D Virus (HDV)] - Rarely occurs in children - Infection must occur in someone already infected with HBV - Coinfection vs superinfection - Parenteral and sexual transmission - Same risk factors as HBV (hemophilia, drug use, endemic areas) - Acute and chronic infections - More severe than HBV and can lead to severe liver damage - Chronic or severe cases need antiviral drugs and possibly a liver transplant - No specific vaccine; HBV vaccine is protective [Hepatitis E Virus (HEV)] - Uncommon in children - Devastating to pregnant women - Fulminant hepatitis - Death (fetal and maternal) - Transmission: fecal-oral route (contaminated water) - Not a chronic condition - Does not cause chronic liver disease - Does not have a carrier state - No vaccine available in the US - TX: Self-limiting, supportive [Biliary Atresia (BA)] - Rare disease that occurs in infants - A blockage in the bile ducts from the liver to the gallbladder causing an abnormal build-up of bile in the liver (cholestasis) - Exact causes unknown (congenital, immune/infection-mediated) - S/S: Jaundice & pale stools (4-8 wks of life), dark urine, hepatomegaly - DX: History, PE, labs, US, HIDA scan, liver biopsy\*, exploratory lap - Early diagnosis is critical, can progress to cirrhosis, liver failure, and death - Nutritional support, vitamins - TX: Portoenterostomy (Kasai procedure), eventually a liver transplant [Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)] - EA -- The esophagus is formed into two segments that do not meet, and the esophagus is unattached to the stomach - Infants with EA cannot swallow milk or saliva - TEF -- A fistula is present which forms an unnatural connection with the trachea - Infants with TEF can swallow milk or saliva, but it leaks through the fistula to the lungs (coughing, choking, aspiration, distention) - May occur separately or in combination; often occur together - Direct cause is unknown; genetic component - Can be life-threatening & must be surgically treated shortly after birth [Clinical Manifestations: ] - "The 3 Cs" - Coughing, choking, cyanosis - Regurgitation and vomiting - Abdominal distention - Respiratory distress after feeding - Frothy saliva [Diagnostics: ] - X-ray of radiopaque NG tube - Rigid bronchoscopy (common) - Barium swallow test (rare) - High-resolution fetal ultrasound [Treatment: ] - Surgery depends on type of anomaly, multiple procedures may be required **[Intestinal Parasitic Diseases- Chapter 6]** [Intestinal Parasites -- Giardiasis] - Protozoa - *Giardia duodenalis * - Crowded environments (classrooms or daycare) - S/S -- abdominal cramping with intermittent diarrhea and constipation, vomiting, steatorrhea, anorexia, FTT - DX -- Stool specimens x 3 - TX -- tinidazole (1^st^) or metronidazole; nitazoxanide (≥ 1yoa) - Meticulous handwashing - Educate caregivers about sanitary practices [Intestinal Parasites -- Pinworms (Enterobiasis)] - Helminth - *Enterobius vermicularis* - Universally present in temperate climates - Easily transmitted in crowded environments - S/S -- intense perianal itching, irritability, restlessness, poor sleeping, bed-wetting - DX -- tape test - TX -- pyrantel pamoate; albendazole (≥ 2yoa) - Single dose, repeated in two weeks - Treat all members of family - Meticulous handwashing - Wash clothes/linens in hot water **[Cleft Lip and Cleft Palate- Chapter 8]** [Cleft Lip and Palate] - Facial malformations, with abnormal openings in the lip or palate, that occur during embryonic development - Most common congenital deformity in the U.S. - May occur separately or together [Causes: ] - Include hereditary and environmental factors - Exposure (i.e., radiation, rubella) - Chromosome abnormalities - Family history - Maternal smoking - Teratogenic medications - Folic acid deficiency [Signs of submucous (soft palate) cleft:] - Difficulty with feedings - Difficulty swallowing, with potential for liquids to come out nose - Nasal speaking voice - Chronic Otitis Media [Consider the ESSR method:] - **E**nlarge the nipple opening - **S**timulate the sucking reflex - **S**wallow normally - **R**est [CLEFT LIP REPAIR (3-6 MO)] - Provide analgesics for pain - Provide lip protection - Avoid lying prone or on affected side - Keep surgical site clean/dry and monitor for infection - Use soft elbow/jacket restraints to prevent disruption or injury to the surgical site - Remove often, assess, allow for ROM [CLEFT PALATE REPAIR (\~ 1 YR)] - Provide analgesics for pain - Assess for unsecured oral packing - Avoid oral suction or placing objects in the mouth - Resume feedings, per surgeon - Monitor for infection - Use of soft restraints - Encourage parental bonding - Initiate appropriate referrals **[Genitourinary Dysfunction]** [Urinary Tract Infection] **-**What is it? -Bacterial invasion of the urinary tract from skin or GI flora -2 places of GU system for infection -Upper and lower -Upper: cystitis (bladder), urethritis (urethra) -Lower: pyelonephritis (renal pelvis and parenchyma of kidneys) -**Pyelonephritis is the MOST serious UTI** [Types of UTI's:] **-Bacteriuria:** bacteria **-Pyuria:** WBC's **-Recurrent UTI:** repeat episode of bacteriuria/symptomatic with the same strain **-Frequent UTI: \>**3 UTI's within a 6 month period; does not have to be same strain **-Persistent UTI:** persistent despite treatment with ABX **-Febrile UTI:** fever and physical signs of UTI **-Urosepsis:** febrile UTI coexisting with systemic signs of bacterial illness [Classic Triad of SX:] -frequency -urgency -dysuria \***Cystitis can be asymptomatic\*** **Acute Pyelonephritis: Chronic Pyelonephritis:** **-Signs and Symptoms: -Signs and Symptoms:** **-**fever and chills -HTN -flank pain on affected side -diminished urine -nausea/vomiting -high K+ (acidosis) -tachycardia -urosepsis -tachypnea [Diagnosis]**:** -Urinanalysis: -+ bacteria -+ leukocytes esterase -+nitrite -+blood -urine culture and sensitivity (fresh specimen) \*want LOW epithelial cells \9.5 g/dL with blood transfusions, every 2-5 weeks -monitor for **hemosiderosis** (iron overload). \~will need iron chelation therapy -splenectomy may be needed for severe splenomegaly **Hemophilia** -What is it? S/S: -hemorrhage occurs with minor degree of severity such as circumcision -subcutaneous and IM hemorrhages are common -hemarthrosis (bleeding into the joint-especially knees, ankles, and elbows) -bleeding in the neck, check, thorax causing airway obstruction -hematomas in spinal cord causing paralysis -pain -hemorrhage in GI tract causing anemia Diagnosis: -history of bleeding episodes -laboratory tests -genetic tests Treatment/Management: -administer factor VIII concentrates; monitor PTT -administer pain medication -administer a synthetic form of DDAVP (vasopressin) -maintain bleeding precautions -assess neurological status -teach s/s of internal bleeding -teach how to control bleeding -teach to avoid contact sports -medical alert identification -teach to wear/how to use protective devices Leukemia -an increase of immature WBC's that depress bone marrow production -can be caused from genetic mutations, genetic predispositions, or unknown environmental factors **-more common in boys vs girls** **-more common in caucasians vs African American** -age of onset is usually 2-3 years old **-Acute lymphoblastic leukemia (ALL) is MOST common** S/S: -anemia -infection (due to neutropenia) -bleeding (decreased platelets) -trouble clearing minor infections -pale -listlessness or lack of energy -irritability -febrile -anorexia -weight loss -bruising -petechiae -bone and joint pain \*often found during routine physical\* Diagnosis: -peripheral blood smear that contains "blasts" -hx and physical -bone marrow biopsy Treatment: -chemotherapy -radiation therapy -chemotherapy with stem cell transplant -targeted therapy **Lymphoma** -group of neoplastic diseases that arise from the lymphoid system and hematopoietic systems -2 types: \~Hodgkin lymphoma \~Non-Hodgkin lymphoma **Hodgkin's Lymphoma** -malignancy of the lymph nodes that originates in a single lymph node or a single chain of nodes -usually metastasizes to non-nodal or extra lymphatic sites especially the spleen, liver, lungs, bone marrow, and mediastinum S/S: -mediatinal mass -enlargement of lymph nodes -enlargement of spleen or lvier Diagnosis: -CBC, albumin, and CRP -chest xray -CT or MRI of head/neck/chest/abd/pelvis -PET scan -lymph node biopsy Treatment: -chemotherapy -radiation therapy -monitor for localized skin reactions -fatigue -weight loss -mucosal ulcerations **Protecting Child from Bleeding** -always handle the child gently -assess for s/s of bleeding -encourage use of soft toothbrush and avoid flossing -avoid injections if possible -apply firm and gentle pressure to a needle-stick for atleast 10 minutes -use caution when taking blood pressure -avoid use of rectal suppositories, enemas, and rectal temperatures -avoid nose blowing **Protecting the Child from Infection** -monitor all s/s such as a fever -limit visitors; even if family -mask wearing -plenty of rest -plenty of fluids **Non-Hodgkins Lymphoma** -shares the same symptoms as HL, testing, evaluation, and treatment are the same -Occurs more frequently in older adults **Osteosarcoma** -a type of cancer that is the most common primary bone malignancy in children -**symptoms of early disease are attributed to extremity injury or growing pains,** making diagnosis delayed -typically identified after **long-term unresolved pain** **-**occurs most often in rapid growing bones in adolescents such as distal femur, proximal tibia, and proximal humerus -often metastasizes to chest; asymptomatic lung problems S/S: -hx of injury to affected limb -hx of discomfort to affected limb -warmth, erythema, and tenderness at the site of the tumor -shiny appearing shin and taut (tight) with dilated blood vessels -limited ROM of affected limb -palpable mass (sometimes) Diagnosis: -CT or MRI (including chest to check for lung metastases) -skeletal scintigraphy -biopsy -CBC -Serum alkaline phosphatase -LDH Management: -educate child and family -amputation -post op: pain and infection prevention -stump care is essential -prosthesis can impact issue of body image and enable independent ADL's -phantom limb pain: burning, aching or cramping in missing limb -mirror therapy **Wilm's Tumor** -Nephroblastoma that arises from the renal parenchyma of kidney -cause is unknown **-most common kidney tumor of childhood** S/S: -abdominal mass, usually found by parent or PCP during bath or physical exam -urinary retention or hematuria -fatigue -fever -hypertension -abdmonial pain **\*do NOT palpate the mass\*** Diagnosis: -ultrasound, MRI, or CT -renal function labs -electrolyte labs Treatment: -surgery -chemotherapy -may undergo chemotherapy before sx to reduce size of the mass -after removal of tumor, all children receive chemo -radiation therapy Management: -prevent rupture of abdominal tumor -post op: \~monitor GI activity (bowel sounds, stool, abd distention) \~assess for s/s of infection, hemorrhage, changes in blood pressure \~assess urine output of remaining kidney \~monitor intake and output atleast q4 \~maintain NG tube