Pediatric Communicable Diseases PDF

Childhood Communicable and Infectious Diseases Chapter 6 Infection Control Concepts - Decrease transmission of communicable diseases - Standard precautions for any patient o Hand hygiene ▪ Before and after caring o Safe injection processes...

Childhood Communicable and Infectious Diseases Chapter 6 Infection Control Concepts - Decrease transmission of communicable diseases - Standard precautions for any patient o Hand hygiene ▪ Before and after caring o Safe injection processes o Respiratory hygiene/cough etiquette o Gown and gloves if risk of exposure to blood or bodily fluids ▪ Barrier protection - Transmission based precautions o Used in addition to standard precautions o 1 in 31 patients acquire hospital infections per day ▪ Occur between interactions between healthcare providers and machinery and patients ▪ Documentation in epic: wiping the WOWs down? ▪ Opportunity for infection ▪ Preventable o Airborne ▪ Transmission through air ▪ Droplets that have evaporated ▪ Varicella, measles, TB ▪ Negative pressure room, isolation Airborne infection isolation room Ventilates air inside patient’s room outside, airborne particles get diluted o Droplet ▪ Contact to mucous membranes from large particles ▪ Sneezing, coughing, crying, talking ▪ Mumps, influenza, pertussis, epiglottitis o Contact ▪ Direct contact, skin to skin ▪ Transfer of organisms when bathing, repositioning ▪ Indirect: contaminated object in the environment Stethoscope, WOW  ▪ Use clinical judgment for gowns, gloves, and masks Gloves and gowns when changing diapers – especially for explosive stools Gowns if child is likely to vomit/spit up/burp while feeding ▪ RSV, Varicella, skin conditions (impetigo, scabies, lice), c. diff Immunizations: Nurse’s Role - Decline of infectious diseases due to immunizations - Begins during infancy - Completed by early childhood - Nurse caring for preterm baby o Receive full dose of vaccine at appropriate chronological age - Be familiar with the schedule o What immunizations a child should get and how many by each age - Be aware of adverse effects - Live vaccines cannot be given to children with recent blood transfusion or immunoglobulin administration o Wait 3 months before giving live MMR or varicella - Pregnancy is contraindicated for MMR o Slight risk of fetal damage - Breastfeeding is not contraindicated for any vaccine - Need parental consent to vaccinate a child o Give VIS sheet - Fewer objection for vaccines in deep muscle vs subcutaneous o Can give a deltoid (as long as muscle mass is adequate), lateral muscle o Dorso gluteal is not recommended due to sciatica risk o Vastus lateralis for newborns, infants, toddlers - Emla can be used to decrease pain - Use distraction o Breastfeeding, take a deep breath - Use neutral terms o “here we go” o “here comes the sting” - Make sure documentation is complete o Day, month, year o Manufacturer and lot number o Name, address, title o Site, route  o Parents provided verbal informed consent, provided VIS sheet Nursing Care Management – Communicable Diseases - Be familiar with what causes communicable diseases - Clues on physical assessment findings o Transmission based precautions implemented o Exposure: family, home, recent travel? o Prodromal symptoms: early evidence ▪ Fever or rash o Up to date in immunizations? o Underlying disease/comorbidity? - Provide comfort/support, document findings o Primary prevention = immunizations o Handwashing o Reduce transmission - Preventing complications (especially in immunocompromised patients) Diphtheria - Rare in the US - Significant morbidity - Administered in combination - DTaP - Agent – Corynebacterium diphtheriae - Prevention – 2 months, 4 months, 6 months, 15-18 months, 4-6 years o Boosters given every 10 years for life - Transmission – direct contact with infected person, carrier, or infected object - s/s o Respiratory infection symptoms that progress in severity o Bull's neck: lymphangitis, large cervical lymph nodes, can barely tell where the neck begins o Fever, cough o Mucous membranes become white/gray - Treatment o Antibiotics – penicillin/erythromycin o Equine antitoxin ▪ Given IV ▪ Neutralizes diphtheria toxin o Very effective in combination o Bedrest, comfort measures  - Precautions – droplet and standard Chicken Pox (Varicella) - Agent – varicella zoster virus - Transmission – direct contact and respiratory secretions - Prevention – vaccine, 2 doses - s/s o Early prodromal symptoms ▪ Fever, malaise o Itchy rash, begins as macule, then vesicle, then pops ▪ Centripetal distribution ▪ More on trunk and face, less so on arms and legs o Supportive - Precautions – standard, airborne if hospitalized, contact until lesions are crusted over o Child is contagious 1 day before rash appears and remains until all vesicles crust over o Child kept home, away from vulnerable people (immunocompromised) o A week after onset of disease - Secondary infections can happen through itching o Skincare o Bath and change clothes and linens o Calamine lotion o Keep fingernails short and clean to make it less likely to cause damage o Put mittens on child Erythema Infectiosum (Fifth Disease) - Agent – human parvovirus 19 - Transmission – blood/blood products, respiratory secretions - s/s o Fever that persists despite tylenol for 3-7 days o Cough, mild URI symptoms o Slapped cheek appearance - Treatment o Tylenol, NSAIDs to bring fever down or discomfort o Supportive care - Precautions o Hospitalized: standard  o If immunosuppressed/bone marrow suppression: droplet ▪ Risk of aplastic crisis - Pregnancy: should not care for aplastic crisis or fifth disease due to risk of fetal injury Exanthem Subitum (Roseola Infantum) - Agent – human herpesvirus 6 - Transmission – year round, happens in kids less than 3 years of age o No reported contact with infected individual in most cases o Peak age – 6-15 months - s/s o High fever up to a week o Rash appears and fever goes away ▪ Macules and macropapules ▪ Rose/pinkish color ▪ Spreads to neck, face, extremities ▪ Not itchy ▪ If pressure, rash starts to fade o Bulging fontanel o Inflamed throat o Cough o Coryza – runny nose - Treatment o Antipyretics to help with fever - Complications – febrile seizures, encephalitis, hepatitis o Rare - Precautions – standard o Seizure precautions and monitor child Measles (Rubeola) - Agent – viral - Transmission – direct contact from respiratory system - School entry age (4-6 years) - Early s/s o Prodromal: fever, malaise, runny nose, conjunctivitis o Koplick spots: small red spots, small blue/white center ▪ Found on buccal mucosa, opposite molars ▪ Appears two days before the rash  o Rash: 3-4 days of illness - Treatment o Prevention - part of MMR vaccine o Antibiotics: secondary bacterial infections that occur in high-risk kids o Supportive care, bedrest - WHO recommends vitamin A for measles o Vitamin A deficiency is risk factor for severe measles - If hospitalized o Airborne precautions until day 5 of rash Mumps - Agent – paramyxovirus - Transmission – direct contact with or droplet spread from saliva - s/s o Parotid gland is enlarged (salivary glands) ▪ painful/tender o Prodromal symptoms: fever, headache, malaise, anorexia, earache - Treatment o Prevention – MMR vaccine o Analgesics for pain o Antipyretics for fever o If refusal to drink, worried about dehydration – possible IV fluids - Precautions – standard + droplet + contact precautions Pertussis (Whooping Cough) - Agent – bordetella pertussis - Transmission – spread by direct contact to droplets - s/s o Catarrhal stage ▪ URI symptoms for 1-2 weeks o Paroxysmal stage ▪ Gasping/whoop cough ▪ Spasm coughing – short and rapid for 4-6 weeks ▪ Cyanosis - Prevention – vaccines o DTaP - Precautions – droplet and standard Rubella (German Measles) - Agent – rubella virus - Transmission – direct contact from droplets - Age – 4-6 years o Concern in pregnant women – serious risk for developing fetus o Vaccines protect unborn child rather than person immunizing - s/s o Mild infection in most kids o Low-grade fever, headache, malaise, sore throat o Rash ▪ First on face, and spreads down by the end of the first day until body is covered ▪ By third day, less on trunk and more on the extremities - Treatment o Supportive care - Precautions – droplet and standard precautions Scarlet Fever - Agent – group A beta hemolytic streptococci - Transmission – direct contact from droplets o Strep that wasn’t treated = risk - s/s o Prodromal: sudden high fever, bad breath o Enanthema: rash inside the body ▪ Enlarged tonsils, swelling, exudate covering tonsils ▪ Strawberry tongue o Exanthema: skin rash ▪ Pink ▪ Looks like sandpaper, bumby - Treatment o Penicillin o Supportive care o Quiet activities appropriate for age o Analgesics - Precautions o Standard o Droplet until on antibiotics for 24 hours Influenza (Flu) - Agent – influenza virus (varies from year to year) - Transmission – direct contact - Prevention o Vaccines, first shot at 6 months and then annually - s/s o Sudden fever, cold-like symptoms, malaise, URI symptoms, anorexia - Treatment o Antiviral approved for kids ▪ Tamiflu (older than 2 weeks) ▪ Rilenza (older than 7 years) ▪ N/V, difficulty breathing ▪ Most effective after 24-48 hours o Supportive care - Precautions – standard + droplet precautions if hospitalized COVID-19 - Agent – coronavirus 2 o Acute respiratory syndrome in kids - s/s o Asymptomatic o Majority - fever o Quarter – cough o Most symptoms of a mild nature o Kids developed inflammatory syndrome affecting multiple organs (life- threatening) ▪ Multiple organ damage as a result - Treatment o Vaccine is approved for kids at 6 months of age o Remedezavir: considered for hospitalized kids with increased oxygen requirements o Glucocorticoids for increased oxygen needs/respiratory distress o Ecmo for severe Alterations in Genitourinary Function Renal Development and Function in Infancy - GFR is very low in babies and young children o Cannot get rid of extra water and electrolytes o Really vulnerable to fluid volume overload - Newborn babies cannot concentrate urine o Usually look at urine sp gravity to see if patient is dehydrated ▪ Normal – 1.010 - 1.020 o Cannot rely on sp gravity for newborns to see if they are hydrated or not - Newborns cannot reabsorb sodium and water o Loop of henle is short o Newborns have very dilute urine, so sp gravities are very low ▪ Normal: 1.000 or 1.005 o Length of tubules gradually increases until able to concentrate urine by 3 months Renal System Assessment - Physical assessment o Height, weight, BP o Palpation, percussion o Monitor and document Is and Os o How many mL of urine are they putting out? o If child is in diapers, how do we check urine? - Health history o Hx of UTIs or kidney stones? o Have they had urinary retention? o STDs? Pregnant? Cancer? ▪ Bladder cancer is usually an adult cancer, rare in children ▪ More likely yo see tumor of the kidney (Wilms tumor) o Are they on meds: antibiotics, anticholinergics, antispasmodics to cause urinary retention? ▪ Are they on antibiotics that damage flora o Do they have medical equipment in the GU tract (catheter, stent) o Any urological procedures? o What is their normal pattern of elimination? ▪ Bladder control at 5-6 years ▪ Going on the toilet, but now incontinent? ▪ Sign of UTI or some other disorder Urinary Tract Infection: Nursing Assessment - s/s o N/V o Anorexia o Chills o Nocturia o Urinary frequency o Urgency – do they have the urge to void ▪ Easily assessed for a 4 year old vs a newborn ▪ Check how many diapers they’re having ▪ Check every ½ hour ▪ Visualize urinary system – hesitancy Pain or bladder spasms? o Fever o Foul odor o Blood in the urine o Increase in leukocyte counts o Look at UA, see if any abnormal findings Diagnostic Studies - Urine C and S o What pathogens are growing o When we know bacteria, we can see what antibiotics they’re sensitive to - BUN o Blood test o Newborn: 4-18 o Infant: 5-18 o If elevated, problem indicating kidney disease ▪ The higher, the worse o Can also be elevated if dehydrated ▪ Are they dehydrated? What is the urine output? What’s their intake? o Hemorrhage, bleeding, high protein intake, glucocorticoids, can also increase BUN - Creatinine o Infant: 0.2-0.4 o Child: 0.3-0.7 o Teenagers: 0.5-1  o If elevated, renal disease – indicates worsening renal state - KUB o US of ureters, kidney, bladder o Can show blood flow, stones, cysts - CAT scan or MRI o Check for cancer (mass) o Sometimes need to sedate kid so they hold still ▪ NPO for a few hours before - VCUG o Voiding cystourethrogram o Takes images of the urinary system o Contrast gets injected through urinary catheter until bladder becomes full of contrast o Check if any reflux of urine back into the ureters Normal Urinalysis - pH – 5 to 9 - Sp gravity – 1.001 to 1.035 - Protein - Or dark? Or red? - Newborns produce 1-2mL/kg/hr - Child produces 1mL/kg/hr Urinary Bag - If baby is edematous/diaphoretic o Take cotton ball in diaper, squeeze urine out of ball onto dipstick - Best practice is urinary bag - After collecting specimen, send to lab within 1 hour  o If you can’t do that, refrigerate it in specimen fridge to prevent organisms growing at room temperature Urinary Tract Infection - Kids may not be showing any s/s, but still have bacteria growing - Usually ascends from urethra upwards - Second most common bacterial disease o UTIs account for more than 8 million office visits per year o UTIs result in greater than 100,000 people hospitalized annually o Greater than 15% of patients who develop gram-negative bacteria DIE o 1/3 of gram-negative bacteria infections originate in the urinary tract UTIs: Causes - Upper UTI: pyelonephritis - Lower UTI: cystitis - Pathogens o E. coli o Streptococci o Staphylococcus saprophyticus o Occasionally fungal and parasitic pathogens o Gram negative bacilli from GI tract o Fungal generally after multiple antibiotic courses - More common with immunosuppressed patients or diabetics UTIs: Classification - Upper tract o Can be related to glomerulonephritis following strep o Usually no systemic manifestations o Pyelonephritis – may involve kidneys o VUR – retrograde flow of urine from bladder leading to upper urinary tract - Lower tract o Cystitis – contained in bladder o Urethritis – irritation, infection possibly leading to ascending o Typically causes fever, chills, flank pain UTI: Infections - Uncomplicated infection – occurs in otherwise normal urinary tract  - Complicated infections – stones, obstruction, catheters, diabetes/neurologic disease, recurrent infections Types of UTIs - Recurrent – repeated episodes; nonresponsive to treatment and/or can become subacute - Persistent – bacteriuria despite antibiotics treatment or noncompliance with treatment and/or can become subacute - Febrile – typically indicates pyelonephritis - Urosepsis – bacterial illness, urinary pathogens in blood o Bacteria is not isolated to GU tract, now is spreading o Can cause CV collapse o Any increase in frequency and severity of symptoms? o Responding appropriately? UTIs: Etiology and Pathophysiology - Physiologic and mechanical defense mechanisms maintain sterility o Emptying bladder o Normal antibacterial properties of urine and tract o Ureterovesical junction competence o Peristaltic activity o Do their ureters plug into the bladder like they should? ▪ Are there congenital issues? o Is the patient sexually active? ▪ Can cause break in mucosal integrity, causing organisms to enter o Any obstruction/stones causing a blockage of urine flow? o Defense mechanisms: are they immunosuppressed? - Alteration of defense mechanisms increases the risk of UTIs - Organisms are usually introduced via ascending route from urethra o Or a patient can have a bloodstream infection/lymphatic infection - Any medical equipment can introduce organisms – catheters, stents - Common nosocomial infection o Usually E. coli o Seldom Pseudomonas o Usually caused by urologic instrumentation UTIs: Clinical Manifestations - Dysuria  - Frequent urination (>q 2hr) - Urgency - Suprapubic discomfort or pressure - Urine may contain visible blood or sediment (cloudy) - Flank pain, chills, and fever indicate infection of upper tract (pyelonephritis) - Be on the lookout for no symptoms or vague symptoms – could only have a fever, decreased appetite, or fatigue Pediatric Manifestations - Does the child appear ill? Do they have a fever? - Height, weight, BP - Standard frequency to see if diaper is wet: every 2-4 hours - Better chance of seeing what’s happening if checking every ½ hour - Can do a urine dipstick - s/s - frequency, fever, odiferous urine, blood or blood-tinged urine, sometimes asymptomatic other than generalized sepsis UTIs: Diagnostic Studies - Dipstick – identify nitrates, WBCs, and leukocyte esterase - Microscopic urinalysis for confirmation - Culture to determine empirical findings - Collection o Clean catch ▪ If a child can follow instructions o U bag o Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results ▪ May be necessary when clean catch cannot be obtained o Best time to collect urine sample: first thing in the morning, urine is more concentrated - Sensitivity testing determines susceptibility to antibiotics - Imaging studies for suspected obstruction – IVP for abdominal CT UTI Collaborative Care Drug Therapy – Antibiotics - Antibiotics are begun after getting a urine sample (!) - If lab results come back that the organism isn’t reactive to the antibiotic, change the antibiotic - Uncomplicated cystitis – short-term course of antibiotics  - Complicated UTIs – long-term treatment - Bactrim – commonly used o TMP-SMX - Amoxicillin - Cephalexin - Gentamycin, carbenicillin - Pyridium – changes urine color (reddish orange), but soothing for urinary tract mucosa - Combination agents (Urised) used to relieve pain – preparations with methylene blue tint UTI Collaborative Care Drug Therapy for Repeated UTIs - Prophylactic or suppressive antibiotics - TMP-SMX given everyday to prevent reoccurrence o May need prophylactic antibiotics if recurrent UTIs Vesicoureteral Reflux (VUR) - VUR – retrograde/backflow of urine from bladder into ureters - Primary reflux – anomaly - Secondary reflux – obstruction in the bladder - Graded from least to most severe - Increases potential for infection Acute Pyelonephritis – Etiology and Pathophysiology - Caused by a number of different organisms - Urosepsis – systemic infection from urologic source o 15% of children can die from this Glomerular Disease: Acute Glomerulonephritis (AGN) - Teach to take for entire course of antibiotics for strep because glomerulonephritis can occur - Mild to severe in severity - s/s o Can see protein in urine, hematuria (tea colored urine) o Oliguria – decreased urine output o Edema o Hypertension Types of Glomerulonephritis - Most are post infectious o Pneumococcal, streptococcal, viral - May be distinct entity or manifestation of systemic disorder o SLE o Sickle cell disease o Others Glomerulonephritis Symptoms - Generalized edema o Due to decreased GFR o Begins with periorbital o Then lower extremities and pulmonary and ascites - HTN due to increased ECF - Oliguria - Hematuria – bleeding in upper urinary tract = smoky urine - Proteinuria – increased amount of protein = increased severity of renal disease Acute Poststreptococcal Glomerulonephritis (APSG) - Often associated with prior hx of strep throat - Onset is 5-12 days after other infections - Noninfectious renal disease – autoimmune - Often group A beta-hemolytic streptococci - Most common in children 6-7 years old - Uncommon in children younger than 2 years old - Can occur at any age - Prognosis o 95% - rapid improvement to complete recovery o 5% to 15% - chronic glomerulonephritis o 1% - irreversible damage Nursing Management of APSG - Daily weights, Is and Os, measure abdominal girth and document - Manage HTN – loop diuretics, thiazides o Ace inhibitors, Ca channel blockers, beta blockers - Nutrition – regular diet recommended unless increased edema (then no salt added) - Most kids don’t feel like eating – anorexia  - Bed rest is not necessary or a requirement but kids don’t feel well, so they self- restrict - Antibiotic ordered if strep continues, otherwise not used Nephrotic Syndrome - Common occurrence in glomerular injury - Not a disease, but clinical state of proteinuria, low albumin in blood, hyperlipidemia - Characteristics o Proteinuria o Hypoalbuminemia o Hyperlipidemia o Edema o Massive urinary protein loss Types of Nephrotic Syndrome - Can have minimal change nephrotic syndrome – very little structural change to glomeruli o Also called – idiopathic nephrosis, nil disease, uncomplicated nephrosis, childhood nephrosis, minimal lesion nephrosis - Can be congenital - Considered chronic, 80% have complete remission with steroid treatment o 20% will continue to have relapses until adulthood Changes in Nephrotic Syndrome - Glomerular membrane o Normally impermeable to large proteins o Becomes permeable to proteins, especially albumin o Albumin lost in urine (hyperalbuminuria) o Serum albumin decreases (hypoalbuminemia) o Fluid shifts from plasma to interstitial spaces - Hypovolemia - Ascites Nephrotic Syndrome Management - Supportive care o Rest and quiet activities appropriate for age - Diet – regular diet if remission, if edema then sodium restriction o No evidence to support high protein  - Steroids at time of dx, decrease proteinuria o Prednisone has least number of side effects - Drug alert: all steroids o Concerned about obesity, GI bleeding, bone loss, infections o Monitor for side effects o Some children don’t respond to steroids, then use Cytoxan - Diuretics – decrease fluid overload Family Issues - Family support o Kids are at home during relapse unless severe edema or proteinuria o Do they have the support they need o Notify if worsening symptoms o Social isolation – tired, don’t feel well, no energy, immunosuppressed, change in physical appearance due to edema (self esteem) Nephrotic Syndrome Nursing Interventions - Ensure adequate fluid intake (patients with urinary problems may think fluid intake will make them more uncomfortable) o Dilutes urine, making bladder less irritable o Flushes out bacteria before they can colonize o Avoid alcohol, caffeine, citrus juices, chocolate, and spicy foods - Discharge to home instructions - Follow up on urine specimens or cultures as needed o Recurrent symptoms typically occur in 1 to 2 weeks after therapy o Encourage adequate fluids even after infection o Low-dose, long term antibiotics to prevent relapses or reinfections o Explain rationale to enhance compliance - Aseptic technique during catheterizations - Avoid unnecessary catheterization and early removal of indwelling catheters o Prevents nosocomial infections o Wash hands before and after contact o Wear gloves for care of urinary system o Routine and thorough perineal care for all hospitalized patients o Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals Defects of the Genitourinary Tract - Phimosis o Narrowing of preputial opening of foreskin o Prevents retraction of foreskin over penis o Normal finding in babies and young boys o Nothing to do, reassure parents that this is normal o Will go away and disappear as child grows - Hydrocele o Fluid filled mass in the scrotum o Swollen, enlarged, painful, red, pressure at base of the penis o Dx by shining a light to illuminate fluid filled area ▪ Does light travel through o Resolve by 1 year of age, then surgery o Post op ▪ Temporary swelling, discoloration of scrotum, if dressing is used, removed by 2-3 days, then bath ▪ Straddle toys avoided for 2-4 weeks ▪ If older boy, strenuous activity avoided for 1 month - Cryptorchidism o One of the testes does not descend down due to narrow canal or lack of sensitivity to maternal hormones, or congenital defect of gonads o Concerns: testes fail to descend, higher temp in abdomen, so increased risk of infertility and malignancy o Usually descend spontaneously by 3 months, if not orchiopexy is performed ▪ Remove testes from abdomen into the scrotum ▪ 6 months of age before doing this ▪ Prevent infection and pain control - Epispadias and hypospadias o Congenital defects, urethral meatus is in abnormal location o Epispadias ▪ Tip of penis is on top of shaft o Hypospadias ▪ Tip of penis is on bottom of shaft ▪ Occurs with downward curvature of penis, and associated with cryptorchidism o Dx: visual at time of birth, or US o Surgery done at 6-12 months to minimize psychological effects o Child should have adequate urinary stream at end of surgery  o Dorsal foreskin may be used for this surgery, so child should not be circumcised before surgery o Post op ▪ Protect surgical site from injury ▪ Wrapped in dressing, stent in place ▪ Fresh blood on dressing and stent, can happen immediately post op Not afterwards ▪ Over next few hours, urine should become less and less bloody ▪ Slight blood tinge for a few days o Stent shouldn’t get accidentally pulled out ▪ Medical restraints used o Adequate fluid for adequate urine output to keep stent patent o If no urinary output within 1 hr, concern that stent is obstructed o Pain control – caudal nerve block o Anticholinergic for bladder spasms o Antibiotics until stent comes out - Discharge instructions o Double diapering: use two diapers, first diaper collects stool, outer diaper collects urine o Prevent injury ▪ Shouldn't bathe until stent is out ▪ No straddle toys or straddling on hip for at least 2 weeks Hold child another way ▪ If fever, urine that comes out any other way, bright red bleeding, call hospital - Chordee o Can occur in conjunction with epispadias/hypospadias o Hooked or crooked condition of the penis o Can be corrected surgically - Exstrophy of the bladder o Posterior bladder pushes out through lower abdominal wall o Females: split clitoris o Boys: short penis ▪ Usual inguinal hernias and cryptorchidism o Surgical repair to repair abdominal wall o Pre op ▪ Cover exposed bladder with plastic wrap or transparent dressing to keep mucosa moist until surgery  ▪ Avoid abduction of legs ▪ Maintain good alignment and provide psychosocial support o Post op ▪ Monitor Is and Os ▪ Urine is blood tinged initially ▪ What is expected output in weight in kgs ▪ Administer medications: antibiotics, analgesics, and muscle relaxants ▪ Prevent complications ▪ Avoid leg abduction ▪ Observe for: wound infection, UTI, obstructions, increase bladder spasms, decreasing urine output , bright red blood - Obstructive uropathy and posterior urethral valves o Malformation of the urinary tract, obstruction ▪ Abnormalities resulting in urine backflow into the kidneys ▪ Patho – several congenital lesions o Obstruction may occur in either the upper or lower urinary tract ▪ Common sites of obstruction – ureteropelvic valve, ureterovesicular junction, posterior urethral valve o Risk of renal failure esp if bilateral kidney involvement Obstruction Sites in the Urinary System - Post op care o Accurate Is and Os o Pain management o Incision care o Diaper placement o Ostomy care o Observe for s/s of infection GU Surgeries: Psychosocial Issues - Self esteem – changes in appearance, functioning, incontinence - Self confidence - Sexual identity - Sexual functioning – fertility Benefits and Complications of Circumcision - Benefits  o Decreased incidence of UTI, sexually transmitted infections, AIDS, and penile cancer o In female partners a decreased incidence of cervical cancer - Complications o Alterations in the urinary meatus o Unintentional removal of excessive amounts of foreskin o Damage to the glans penis Enuresis: Two Types - Primary o Child has never had a dry night o Maturational delay, small functional bladder o No psychological cause - Secondary o Child who has been reliably dry for at least 6 months begins bed wetting o Stress, infections, sleep disorders - Treatment o Multi approach o Fluid restriction o Bladder training o Timed voiding ▪ Enuresis alarms o Reward system o Medications – desmopressin, oxybutynin, imipramine Testicular Torsion - A testicle is abnormally attached to the scrotum and twisted - Requires immediate surgery because ischemia can result if the torsion is left untreated, leading to infertility - May occur at any age but most commonly occurs in boys aged 12 to 18 years Alterations in GI Function Gastrointestinal Structure and Function - Development of the GI tract  o Meconium – first fecal material passed by newborn after birth ▪ Contains residue of swallowed amniotic fluid ▪ Expelled shortly after birth ▪ Shows that GI tract is patent o Swallowing ▪ For first 3 months, automatic reflex, no voluntary control ▪ By 6 months, swallow, able to hold food in mouth, able to spit food out Starting on solid foods - Digestion o Chemical digestion – GI secretions produced by stomach and small intestine ▪ Hydrochloric acid, water, electrolytes o Mechanical digestion – churning food o Peristalsis – moving the food down with muscle contractions o Chyme – partially digested food along with acidic substances - Absorption o Small intestine – pump and osmosis o Large intestine – completes absorption of water and sodium ▪ Colonic bacteria – synthesize vitamin K, B12, and some of the vitamin B complex o Bacteria can affect color, odor of stool, amount of gas Clinical Manifestations - Failure to thrive – with some GI disorders of kids, kid stops growing (no longer accelerating) or remaining below the 5th percentile for height and weight o Very small, not as tall or weigh as much as they should o Could come with a developmental delay Assessment of GI Function - Known GI disease or trying to rule it out o Malabsorption – not absorbing nutrients, affects growth o Fluid and electrolyte disturbances – diarrhea? o Malnourished – not taking in nutrients needed o Poor growth - Tests assessing GI function o Preparation for nurse: preparing child or family ▪ Supporting child that needs dx test and the equipment is scary o Collecting specimens/stool specimens to check for c diff or parasites  o Barium swallow o Enema o Abdominal x-ray o Upper GI series o Abdominal US o Endoscopy o Maybe CAT scan or MRI to check organs Imaging - Make equipment child friendly - Prepare child for procedures – practice holding still Upper GI Series - Need to swallow barium or contrast - Barium travels through GI tract and radiologist can look at imaging to see structure of esophagus/stomach/intestines - Preparation - NPO before procedure for 4 hours (younger kids) or 8 hours (older kids) - After barium swallow, assess for clay-colored stools o Shows that barium has been eliminated – is working through GI system o Important to document in epic o If not passing clay-colored stools – obstruction o Should happen within a few hours ▪ Assess what a normal bowel movement pattern is for the child Abdominal US - Describe gel – cool, wet, gloppy - Emits ultrasonic waves that bounce off tissues and organs - Non-invasive, doesn’t hurt - Practice lying still CT Scan and MRI - Provide atraumatic care – make it less scary - CAT scan - radiation to look at GI structures, provides 360-degree image in two dimensions o Are they going to use contrast dye? o Assessing allergies and family medical hx? ▪ Allergies to contrast dye, iodine, or shellfish?  o Prepare for loud noises o “going through a donut” o Make sure kids drink after - stay hydrated ▪ Want to be sure contrast dye comes out, can be toxic to the kidneys ▪ Or administer IVF ▪ Monitor urine output, is it normal for age? 1-2mL/kg/hr for newborn and 1mL/kg/hr for older kids - MRI o Really loud, sounds like banging on the wall o Ensure they’re safe o Have to hold very still o Large magnet – visualizes internal body structure o More enclosed than a CAT scan o May use contrast dye here too o Can offer headphones with no magnet in it o Make sure no metal on child – jewelry, earrings o May need sedation to hold still Endoscopy - Visualizes the GI tract – see abnormalities, lesions - If need biopsy - Need sedation - pH monitoring for GERD o What is the acidic pH of GI secretions o What is the severity of the reflux - NPO for 4 hours before tube is inserted – check medications child has been on o Antacids or PPIs need to be stopped 24 hours before pH monitoring is done o Sometimes stopped up to 7 days before – interferes with the pH Stool Sample - WBCs - Ova and parasite - Bacterial cultures - Fecal fat - Stool pH - Rotazyme (rotavirus) - Blood Dehydration - Volume depletion, fluid volume deficit - Seen in kids with diarrhea – losing fluids and not replenishing orally - Isotonic diarrhea, hypotonic diarrhea, hypertonic diarrhea o Are water and electrolytes lost in equal amounts? Or one more than the other? o Usually isotonic - Mild/moderate/severe dehydration o Use weight initially as baseline – how much weight has been lost? ▪ Body weight is primarily water, so weight goes down with dehydration ▪ Good indicator of severity of dehydration o More than 10% of weight = severe ▪ Tachycardia, no production of tears, low urine output/no urine output, orthostatic hypotension to shock o 6-9% of body weight = moderate ▪ Cap refill 2-4 seconds, thirst/irritable, pulse increased with orthostatic BP, dry MM, normal to sunken fontanel o 3-5% of weight = mild ▪ Slight thirst, cap refill less than 2 seconds, vitals normal - Be on alert for hx of fluid loss, vomiting and diarrhea, and seeing signs of dehydration o Gear nursing assessment to possible circulatory failure and cardiovascular shock - Check weight, cap refill, thirst, irritability, orthostatic BP Mild to Moderate Dehydration - Oral rehydration solution – pedialyte - Get sodium back - Continue breastfeeding too - 50mL/kg of solution every 4-6 hours - Kids may have a hard time drinking – use spoon, needleless syringe every 1-5 ins as tolerated - When rehydration is complete, symptoms have improved, weight gain, stable – started on regular diet o BRAT is too restrictive - Replace each diarrhea stool/vomiting with 10mL/kg ORS Severe Dehydration  - Give IVF when child cannot tolerate ORS (30mL/hr for infants and 60mL/hr for older children) - Isotonic crystalloid, same osmolality as intracellular fluid o D5W and NS, maybe add sodium bicarb o 20mL/kg bolus over 20 mins- 1 hour ▪ Repeat bolus up to 3x ▪ Then start maintenance fluids - Should urinate 2x before adding potassium o Hold K if prescribed to not cause kidney injury IV Fluid Maintenance Rate - Child up to 10 kg – 100mL/kg/24hrs - If 11-20kg, 1000L + 50mL/kg above 10kg/24hrs - If greater than 20kg, 1500mL + 20mL/kg above 20kg/24hrs Diarrhea - Acute - happens suddenly - Chronic – more than 14 days - Intractable diarrhea – happens at infancy o Lasts two weeks o No pathogens, no treatment - Chronic nonspecific diarrhea o Irritable colon for infants and toddlers o Often undigested food particles - Etiology and pathophysiology o Rotavirus – promote vaccine ▪ Most common cause for children under 5 o Bacterial causes – salmonella, yersinia, shigella ▪ Turtles cause salmonella ▪ Antibiotic administration can cause c diff o Are they in daycare? ▪ Fecal-oral route of transmission ▪ Coming into contact with sick children o Changes in diet? - not tolerating it - Labs o Dehydrated – CBC, electrolytes o BUN and creatinine o Stool culture  o Specific pathogen causing it? - If diarrhea persists for more than a few days and everything is negative o Stool sample to check for parasites - Therapeutic management o Assess fluid/electrolyte imbalance o Assess hydration status and rehydrate o Start maintenance fluids o Reintroduce regular diet to adequately meet needs for growth and development o ORS – decrease duration of illness, decrease vomiting o IV solution – saline solution with D5 dextrose and water, sodium bicarb added, add potassium after sure renal function is restored - Nursing care management o Trend assessments over time o Is condition improving or worsening? o If they have stools, replace fluid with ORS o Give small amounts of ORS frequently – maybe NGT inserted o Continuing breastfeeding as tolerated and needed o Educating the family ▪ Hand hygiene, drinking clean water, safe food preparation, fruits and vegetables are washed or peeled o Prevention: rotavirus vaccine o Support family ▪ How many wet diapers per day? ▪ Teach how to administer ORS solution ▪ Addressing concerns Constipation - Decreased frequency or harder consistency or difficulty in ease of stool - Obstipation: extremely long time period between bowel movements - Encopresis: incontinent of stool, fecal soiling that goes around obstruction and leaks out - Usually functional or idiopathic constipation o Can be secondary to a medication or disease process - Can present with chronic constipation o Anything happening at home or school that could be contributing to this? o Starting a new school, starting school, fearful of having a bowel movement at school, fear of lack of privacy Constipation in Newborn and Infancy - Newborn period o Meconium: passed 24-36 hours after birth ▪ If not, Hirschsprung disease, hypothyroidism, meconium plug, meconium ileus, or cystic fibrosis - Infancy o Formula fed infants have higher risk of constipation than breastfed o Interventions ▪ Increasing fruits and vegetables ▪ Increasing fluids with sorbitol – prune juice, apple juice, pear juice Draws water into intestine so it’s easily passed Constipation in Childhood - Environmental changes, lack of privacy - Management o Debulking: water soluble enema, irrigation, increase fiber o Scheduling toilet for kids, preferably after a meal Constipation: Nursing Considerations - Hx of bowel patterns? Medications? Diet? - Age-appropriate ways of adjusting diet, increasing fiber, increasing fluids o Dairy is known to cause constipation o Dietary modifications o Do they need a stool softener, or laxative ▪ Take time to dissolve it well, dissolve in preferred drink o Mineral oil – can cause aspiration and lung injury, should not be given less than 1 year of age - Management of obstruction can take 6-12 months of behavioral/dietary/pharmacologic interventions Vomiting - Forceful expulsion of stomach contents - Projectile vomiting – forceful, up to 2-3 feet - Causes o Acute infectious condition – gastroenteritis o Increased intracranial pressure o Ingestion of chemicals or toxic substances  o Allergies o Kidney disease or obstruction of GU tract o Pregnancy o Psychosocial problems – seen in school age kids ▪ Different routine for them, leaving home, leaving parents - Pay attention to age – what is the pattern o Only M-F before they get on the bus – psychogenic nature o Once? Chronic? Acute? ▪ Chronic can show malrotation in GI tract o Bowel obstruction – green bilious vomit o Projectile – pyloric stenosis o Chemoreceptor trigger zone controls vomiting - Nausea: subject sense they’re going to vomit o Self-report o 0-10 on nausea - Retching: vomiting but nothing is coming up - Dx o Any fluid or electrolyte abnormalities? How much are they vomiting? o Quantify severity of nausea on self report o X ray of chest and abdomen to see anatomic abnormalities o Brain tumor? - brain scan, CAT scan o If vomiting or regurgitating – esophagitis ▪ GI endoscopy could be warranted - Management o Treat the cause o Prevent complications – dehydration, malnourishment o Ondansetron, Dramamine for motion sickness ▪ Continue on a regular schedule as long as they’re vomiting - Nursing management o Strict Is and Os o Aspiration – positioning ▪ Sit upright ▪ Sideways if not upright o Support to parents – tell cause, tell plan o Nonpharmacological: certain food smells ▪ Keep food trays out in the hall Disorders of Motility Hirschsprung Disease - Also called congenital aganglionic megacolon - Congenital disorder – not seen in adults o More common in boys, children with down syndrome, 1 in 5000 live births - Causes mechanical obstruction, inadequate motility of abdomen without ganglion cells - Absence of ganglion cells in the colon o Colon gets huge o Significant abdominal distention o Distention happens above the part of the colon that lacks ganglion cells o Stools become obstructive and can’t pass o Failure of internal anal sphincter to relax o If ruptures, serious infection o The section of colon that’s aganglionic can be anywhere in the colon ▪ Usually around sigmoid colon - Colon accumulates, colon distends, increase of abdominal girth o Make sure you’re documenting abdominal girth pre op and post op o Inflammation of colon (enterocolitis) occurs - Measure abdominal girth and document - s/s o Failure to pass meconium in first 48 hours o Bilious vomiting o Increased abdominal distention o Fever o Enterocolitis o Explosive, watery diarrhea o Appear very sick - Older infants or children o Chronic constipation o Obstructive fecal mass o Impacted with stool o Abdominal distention o Failure to thrive – stop growing or remain below 5th percentile for height and weight ▪ Can cause developmental delays - Dx o Barium enema  o X ray o Confirmed with rectal biopsy ▪ See absence of ganglion cells o Anorectal exam ▪ Catheter with balloon at the end, inserted into the rectum, records pressure on sphincter when balloon gets dilated ▪ Internal sphincter does not relax, remains tight - Management o Need surgery o Surgery depends on where aganglionic portion is and how much colon is aganglionic o Least extensive condition – single surgery without colostomy o More extensive – two surgeries ▪ First: temporary ostomy is placed ▪ Second: pull through procedure, connects working colon to the anus, bypassing aganglionic colon - Priorities pre op o Observe for passage of meconium, if not, Hirschsprung o Keep hydrated, IV fluid o Antibiotics – serious risk of infection if perforation o Monitor Is and Os o Monitor for s/s of impaction – constipation o Decompress gut – NG tube and salem sump, low intermittent wall suction o Daily rectal irrigations for mild cases o Abdominal distention increasing? - measure abdominal girth at umbilicus o If more severe – TPN o Family-centered care: make sure parents bond with the infant - Priorities post op o Monitor for s/s of infection, fever, pain, hydration o Measure abdominal distention, any increase is worrisome o Supporting after surgery o If stage one: teach ostomy care ▪ Pouch adhering to stoma ▪ Assess skin site: pink and intact ▪ No adhesive enhancers o Newborn skin is thin: do not use adhesive enhancers ▪ Could strip the skin ▪ Increases risk for latex allergy  o Make sure to support family and refer to ostomy support groups o Discharge ▪ Family knows s/s of infection, obstruction, malnourishment ▪ Ostomy care ▪ When child has ostomy removed Takedown, reattaching colon to rectum or anus Bowel prep NGT for laxative to clean out bowel – GoLytely Gastroesophageal Reflux (GER) - Can occur at any age - Gastric contents reflux into the esophagus o Irritating to esophagus - Reflux may occur without GERD (with tissue damage) - GERD can occur without regurgitation (spitting up) - Frequency and persistency may make it abnormal - Physiologic until 1 year of age - Becomes pathologic with failure to thrive, no more growing, bleeding, dysphagia - Usually due to relaxation of lower esophageal sphincter - s/s o Spit up o Regurgitation o Vomiting o Hunger o Irritability o Crying o Eating a lot/refusing feedings o Failure to thrive (poor weight gain) - Look for resp changes o Associated with reflux/GERD o Can aspirate gastric contents - Dx o How long o Abnormal findings on physical exam o See gastric acidity o Endoscopy with biopsy to see if abnormality of esophageal cells ▪ Barrett’s esophagus: changes in the cells that increase risk of cancer later in life  o Assess gastric emptying time Complications of Gastroesophageal Reflux (GERD) - Reflux coming into esophagus or into oropharynx - Most often in premature, neurologic conditions, asthma, cystic fibrosis, cerebral palsy - Assessing for abnormalities in GERD o Laryngitis, hoarseness o Pneumonia o Anemia o Barrett’s esophagus o FTT/poor growth Therapeutic Management of GER/GERD - Conservative approach: avoid foods that cause reflux o Spicy, fried, caffeine, citrus fruits/juices - Small frequent meals rather than 3 large meals - Babies: thicken formula o Add 1 TSP to 1 TBSP of rice cereal per 1 oz of formula o May need to enlarge nipple/opening - After feeding: HOB elevated, keep upright - Sleep supine: on back, not on belly - Frequent burping during feeds - Avoid overfeeding - With severe GERD, possible surgery o Nissen Fundoplication o Candidates - persistent resp symptoms, frequent aspirations, no response to management o 1 way valve is created by wrapping fundus around esophageal sphincter o Severe cases - may need G tube for 6-8 weeks after surgery or longer for feeding Nursing Management: GER/GERD - Teach parents to hold infant/cuddle during feeds and keep at upright position - Weigh every day - Small frequent feeds - Thicken feeds and split nipple - Elevate HOB  - Encourage nonnutritive sucking o Especially with G tube and J tube feedig=ngs o Babies derive pleasure from the oral fixation ▪ Pacifier, breast - Educate for G tube and J tube - PPIs or H2 blockers decrease hydrochloric acid secretion, can increase lower esophageal tone Inflammatory Conditions Acute Appendicitis - Obstruction of lumen of appendix in RLQ - Average age is 10 years - s/s o RLQ pain – guarding RLQ, pain greatest at McBurney’s point o Rebound tenderness – palpate RLQ and on rebound is when pain is greatest o N/V o Anorexia o When there’s no pain at all – appendix ruptured ▪ Pallor - Dx o Abdominal US o Lab test: WBCs elevated o C reactive protein elevated (inflammatory marker) - Assessments o Atraumatic care o Administer antibiotics and manage pain o If ruptured – longer length of stay, longer antibiotics, wound care, pain management - Post op o Encourage splinting with a pillow o Do not apply heat or ice to surgical site o NGT to low wall suction o Monitor VS and temp o Monitor for return of BS o Good pain management o NPO – why they need NGT ▪ As bowel sounds return, diet returns Meckel Diverticulum - Outpouching of lower part of intestine - Congenital - leftover piece of the umbilical cord - 2% of population, 2-1 ratio males to females, located within 2 ft of ileocecal valve, commonly 2 cm in diameter, and 2 in in length, 2 types of ectopic tissue (pancreatic and gastric), common before the age of 2 - Some are asymptomatic, others have abdominal pain and bloody/mucus stool - Dx – detect where outpouching is in the lower intestine - Pre op o Transfuse with packed RBCs o IV hydration o Supplemental O2 o Antibiotics o Monitor stool and blood lost - Surgery removes outpouching - Post op o Administer O2 o Pain management o IV hydration o Infection – antibiotics o Assess for BS – NPO until then ▪ NGT to wall suction Obstructive Disorders Paralytic Ileus - Impaired motility – acquired or born with - s/s o Pain, nausea, vomiting o Abdominal distention o Change in stool pattern from baseline Hypertrophic Pyloric Stenosis - Pylorus muscle is enlarged, causes a narrowing of the pylorus, causes obstruction - Common cause of gastric outlet in babies - Pay attention to age – adolescent cannot have pyloric stenosis - Occurs within first few weeks of life - 1 week – 5 months (oldest these kids will be)  - s/s oSpit out a lot oRegurgitation oNon bilious vomiting ½ hour – 1 hour after feeding oProjectile vomiting oSee waves of peristalsis on abdomen oAlways hungry oPalpate olive-shaped mass to the right of the umbilicus ▪ Enlarged hypertrophy muscle o Dehydrated – always vomiting o Metabolic alkalosis can occur - Dx: Abdominal US - Surgery pre op o Correct fluid and electrolyte imbalances o Is and Os? o US shows enlarged pyloric muscle o NPO before surgery, NGT to low intermittent wall suction to decompress stomach - Pyloromyotomy procedure o Muscles are spread apart so food can pass through from the stomach - Post op o IV hydration o Is and Os o Common to vomit post op -document how much vomiting is occurring o Feeding – clear liquids 4-6 hours after surgery ▪ After BS have been heard ▪ 10 mL of pedialyte o Refeeding protocol ▪ Increase volume of clear liquids going from dilute to full strength formula ▪ Advance to breastfeeding or formula 24 hrs post op o Documenting – feeding record and vomiting o Small incision – sealant/glue or steri strips used o Keep incision clean, dry, intact o No bathing until follow up (1 week) o Discharged when taking full-strength formula or breastfeeding Intussusception  - 6 months – 3 years - Telescoping up of intestines o One part of the intestine moves up into another part of the intestine - s/s o Inflammation o Edema o Decreased blood flow o Perforation of intestine o Sudden onset of cramping o Severe abdominal pain o Draw legs up o Pain episodes happen 2-3 times per hour o Bile emesis – late sign o Palpate a sausage shaped mass o Bloody/mucusy bowel movements – currant jelly stools - Idiopathic o Sometimes link to Meckel’s o Sometimes lymphoma o Polyps in colon – intestinal lesions - Management o Decrease obstruction before bowel becomes necrotic o Air enema with or without contrast ▪ Dx in most cases ▪ Could resolve and intestines straighten out o Hydrostatic (saline) enema o If enema doesn’t fix problems, surgery ▪ Surgical reduction and fixation or excision of necrotic segment of colon ▪ Possible temporary colostomy - Pre op and post op o IV fluids o Antibiotics o NGT to low suction – if perforation is suspected o NPO o If severe and perforation, temporary colostomy Malrotation and Volvulus - Malrotation – abnormal rotation around artery during embryonic development  - Volvulus – twisting of intestine, cuts off blood supply, obstruction - s/s o Bilious vomiting in the newborn period - Dx – abdominal x ray - Kids need surgery emergently - Pre op o IV hydration o Antibiotics o NGT - Post op o IV hydration o Antibiotics o Pain management o Observe for s/s of infection Surgical Defects Cleft Lip and Cleft Palate - Cleft lip: incomplete fusion of the lip o Failure of maxillary processes to fuse between 6-12 weeks gestation - Cleft palate: incomplete fusion of the palate o Failure of the tongue to move down at the correct time prevents palatine processes from fusing - Congenital - Cause – combination of genetics and environmental causes o Alcohol, cigarettes, steroids during pregnancy o Seen more in boys than in girls, Asians - Can happen together or separately - Unilateral or bilateral - Dx – often in utero by US - Parents can have very severe but normal reactions/grief responses o Support families o Decrease stigma – community base support group o Encourage to express reactions and feelings o Anticipate emotional reactions Pre-Surgery Management (Both CL and CP) - Pre op  o Inspect lip and palate with gloved finger o Assess ability to suck – aspiration risk o What is weight baseline? o Observing bonding and coping with baby – determine coping o Bring in social work for supportive care o Assess ability to feed – usually impaired o Modeling ▪ Role model how to care for baby ▪ Prepare for feeding issues o Decreased ability to suck – special feeding devices ▪ Longer nipple, softer nipple with a wider opening, one way valve o Positioning ▪ Hold upright for ½ hour after feeding ▪ Feed slowly, burp frequently ▪ Support the cheeks and chin o Bulb suction if pooling of formula, keep suction at bedside o Cleft lip: usually able to breastfeed without difficulty ▪ Difficulty with cleft palate o Mom and baby should be encouraged to try pumping and putting breastmilk into specialized feeding devices o Encourage nonnutritive sucking to help with oral fixation o Consult breastfeeding specialist - Surgery 2-3 months of age to make a more symmetrical appearance o z-plasty procedure o Logan bow used to protect surgical incision post op o Post op ▪ Don't let baby suck on pacifier or nipple, nothing in the mouth ▪ Monitor Is and Os ▪ Minimize crying/pain ▪ Position with HOB elevated 30 degrees ▪ Elbow immobilizers may be used to protect suture line ▪ Suture line care as ordered by MD Cleanse with saline or dilute hydrogen peroxide to remove crusts and minimize scarring Apply antibiotic ointment if prescribed - Cleft palate repair o Pre op ▪ Should be weaned from bottle or breast prior to surgical procedure  Surgery around 1 year of age after teeth have erupted and before the ▪ child is talking to promote better speech outcomes ▪ Poor speech outcomes if done after 3 years of age o Post CP surgery repair ▪ Ensure proper airway and positioning ▪ Side-lying immediate post op to facilitate drainage ▪ Suction with bulb syringe only ▪ NPO for 4 hours, then clear liquid for 24 hours, then liquid diet for several days up to 2 weeks, then soft diet for 6 weeks following palate repair ▪ Protect the suture site ▪ Avoid injury to palate with syringes, straws, hard sippy cups ▪ Hold upright for 30 mins post feeds ▪ Pain management ▪ Support family Long Term Referrals - Prone to otitis media - Feeding - Hearing - Delayed or altered speech development - Dental/orthodontic care - Psychological/social acceptance - Team approach to care Hernias Types of Hernias - Umbilical o Common in the newborn period o Typically resolves in the first years of life o Nursing care management ▪ Assessment ▪ Anticipatory guidelines and education to family - Inguinal o Pathophysiology o Clinical manifestations ▪ Hernia vs incarcerated or strangulated hernia  o Therapeutic management o Nursing care management ▪ Assessment ▪ Preoperative care ▪ Post op care ▪ Support to child and family Review Session A nurse is planning to administer recommended immunizations to a 2-month-old infant. Which of the following vaccines should the nurse plan to give? - Rotavirus (RV), DTaP, Influenza B (Hib), Pneumococcal conjugate (PCV13) When should the first Hep B vaccine be administered? - At birth, held for premature and weighing less than 2 kg if the mother is hep b negative as well Which patient would you be cautious to give the Rotavirus vaccine? - 2-month-old with spina bifida, 4-month-old with chronic GI disease, 6-month-old with lactose intolerance o Severe GI limitation and worse problems with patients with these diagnoses A nurse is assessing a client who has pertussis. Which of the following findings should the nurse expect? - Runny nose, cough with a whooping sound Which of the following disease is not spread by indirect or direct contact with respiratory secretions?  - Mononucleosis/Epstein Barr Virus – spread through oral secretions o Like Fifths disease and Chicken Pox What are the clinical manifestations of Fifth’s Disease? - Mild URI symptoms/cough, red rash on face “slapped cheek” appearance A nurse is caring for a 5-year-old who weighs 44 pounds, the child has experienced severe diarrhea the last 24 hours and cannot tolerate PO. The MD has ordered D5 ½ NS to run at a maintenance rate. What rate does the nurse program the IV pump? - 63mL/hr o For 20kg and over: 1500mL + 20kg/hr for every kg over 20/day o Up to 10 kg: 100mL/kg/day o 10-20kg: 1000mL + 50mL/kg for every kg above 10/day As the nurse caring for a 2-week-old neonate, which of the following clinical signs/symptoms indicate Hirschsprung disease? - Failure to pass meconium in first 48 hours, abdominal distention, fever - Also: bilious vomiting and enterocolitis Which of the following actions by the new graduate nurse caring for. 12-month-old immediate post op cleft palate surgery warrants the resource nurse to intervene? - Gives baby sippy cup for comfort – don't give a straw either A nurse in the ED is caring for a patient that presents with fever, nausea, and severe abdominal pain. After MD evaluation, the child is diagnosed with appendicitis. What assessment of the patient should the nurse report to the MD immediately. - Child reports their belly doesn’t hurt anymore – ruptured appendix, now an emergency A nurse is caring for a child with bloody mucus stools inpatient. The child is diagnosed by the medical team with Meckel’s diverticulum. What are he anticipated interventions the nurse should prepare to do for this child? - Establish IV access for blood transfusion, start IV maintenance fluids as ordered, monitor blood loss in stools o NGT and LWS is post op prevention to alleviate gas burden after surgery while NPO A 3-month-old presents to the ED with projectile vomiting and FTT. After evaluation he is diagnosed with pyloric stenosis. What are the other expected manifestations of pyloric stenosis the nurse should know? - Olive shaped mass right of the umbilicus, visible peristalsis A nurse is caring for a school-age child who has acute glomerulonephritis. Which of the following findings should the nurse report to the provider? - Blood creatinine 1.3 mg/dL A new grad NICU nurse is caring for a newborn with bladder exstrophy. What are appropriate interventions for this newborn pre-operatively? - Covering exposed bladder, providing skin protection from urine, using postural techniques to maintain alignment of hips and legs Which statement by the baby’s mother indicates misunderstanding of post op education by the nurse for epispadias correction surgery? - He can use his walker for play time A nurse is providing teaching with the parents of a child with enuresis about behavioral therapy management. Which of the following statements by a parent indicate understanding? - We can reward our child when they have dry nights