Peds Exam Study Guide 2 PDF

1 Pediatrics – Examination Two - Study Guide Cleft Lip &/or Palate – page 665-667. Causes of Cleft Lip Clip or palate is multifactorial combination of environmental and genetic influences. Cleft lips may be unilateral or bilateral and may occur in combination with clef...

1 Pediatrics – Examination Two - Study Guide Cleft Lip &/or Palate – page 665-667. Causes of Cleft Lip Clip or palate is multifactorial combination of environmental and genetic influences. Cleft lips may be unilateral or bilateral and may occur in combination with cleft palate. Cleft palate may not be detected at birth if a cleft lip is not present Diagnosing Cleft Lip Physical exam using gloved finger placed in mouth First sign may be formula coming out of the nose during feeding Complications of Cleft Lip Most at Risk for Cleft Lip Feeding Cleft Lip is more common, male predominance Swallowing Higher in Asians; lowest in African Americans Speaking Most common craniofacial malformation Impaired bonding between mother and baby (Occurs in 1 out of 700 births worldwide) Nursing Interventions for Cleft Lip Elevate head after feeding Burp frequently Do not feed longer than 20-30 minutes, supplement with tube feeding (small frequent meals) Taking Folic Acid (may help during pregnancy to decrease chances of cleft lip. Treatment for Cleft Lip Reconstruction surgical repair: Fisher repair or Millard rotation – advancement technique Cleft lip repair is usually performed between 3 and 5 months of age, however the repair may occur earlier depending upon the surgeon’s preference. Logans Bow is used to keep cheeks together Post Cleft Lip Surgery Soft elbow restraints immobilizers (used for 2 weeks to prevent infant from putting fingers in mouth) Keep suture line clean Avoid prone position Prevent crying or sucking Child should be supine when not drinking or eating ****Parents experience guilt, disappointment, grief, sense of loss, and anger. Provide photos of infants/children with cleft lip or cleft palate before and after surgical repair to parents and family members.  2 Esophageal Atresia and Tracheoesophageal Fistula – pages 667-669 Esophageal Atresia malformation resulting from failure of the esophagus to develop as a continuous tube during the fourth and fifth week of gestation; 90% of those affected also have a Tracheoesophageal fistula (esophagus may end in a blind pouch or develop a pouch connected to the trachea by a fistula) Esophageal Atresia with Tracheoesophageal fistula Maintain NPO immediately and suction secretions Symptoms of Esophageal Atresia Salvation/drooling Cyanosis Choking Coughing Remember to: Assess for respiratory distress and assess lung sounds carefully ******Esophageal Atresia is a surgical emergency!!!! Preoperative Care of Esophageal Atresia Initiate NPO status Elevate the head of the bed 30 to 45° to prevent reflux aspiration Monitor hydration status and fluid electrolyte balance administer IV fluids Assess and maintain the patency or the oral gastric tube Avoid irrigation of the tube to prevent aspiration Have oxygen and suctioning equipment readily available Post Operative Care of Esophageal Atresia Administer total parenteral nutrition TPN Administer antibiotics until the esophageal anastomosis is proven intact and patent Oral feedings should start within a week after surgery  3 Omphalocele and Gastroschisis – pages 669-670 Both are congenital malformations; Intraabdominal contents herniate through the umbilical cord. Omphalocele – intestines fail to return to the abdominal cavity during the 10th to 12th week of gestation, larger defects might contain intestines, stomach, liver, and spleen – the abdominal contents are contained in a sac composed of peritoneum, Wharton jelly, & amniotic membrane. Gastroschisis is a congenital defect of the abdominal wall resulting in the protrusion of bowel through the defect to the side of the umbilicus, no membrane covers the organs in gastroschisis. Nursing Management for Omphalocele and Gastroschisis Strict sterile technique Radiant warmer to maintain newborn's temperature Cover the dressing with plastic wrap to decrease heat and fluid loss Maintain low suction to the oral gastric tube to prevent intestinal distension establish an IV line to maintain fluid and electrolytes and provide a route for antibiotic therapy Nursing Interventions for Omphalocele and Gastroschisis Post Surgery Placing infant feet first into a bowel bag (large sterile clear bag) that extends to the nipple line of the infant and is secured with ties. Monitor respiratory cardiac and intake and outtake pain management encourage the patient to touch the newborn Be alert for complications such as short bowel syndrome *****Protect the protruding organs, preventing infection, hypothermia, and of course injury both defects need to be corrected once the abdominal cavity can accommodate the intestinal organs. The infant will remain in neonatal intensive care unit (NICU) with surgical capability for repairing the defect(s).  4 Imperforate anus – pages 670-671 Congenital malformation of the anorectal opening – incomplete development or absence of the anus Signs that a baby may have Imperforate Anus Abdominal distention (swelling) No anal opening No visible anus Stool coming from vagina or urethra Newborn does not pass meconium within 24 hours An unusual appearing anal dimple Treatment for Imperforated Anus Posterior sagittal anorectolplasty creating an animal opening where one was missing Anoplasty where the is connected to the genitals this involved moving the opening to the correct location Nursing Interventions and Considerations for Imperforated Anus May have to provide colostomy care use barrier cream on the area and clean it once daily with soap and water avoid frequent use of soap and water Inguinal Hernia and Umbilical Hernia – page 671-972 Inguinal hernia: note the bulge in the inguinal (groin) area. Boys are more likely than girls to develop Assess for a bulging mass in the lower abdomen or growing area To reduce the hernia temporarily pushing it back through the external ring Treatment is Surgery WITHOUT it can lead to a incarcerated hernia that lead to bowel strangulation Teach family how to reduce the hernia Teach parents that the child's hernia becomes hard discolor or painful they should immediately call the physician or go to the emergency room. Umbilical hernia: note the protrusion in the umbilical area. caused by an incomplete closure of the umbilical ring More common in preterm infants and African Americans Assess whether the hernia can be reduced. Notify the surgeon if the hernia will not reduce Operative repair is not as likely with umbilical hernias The use of home remedies to reduce an umbilical hernia should be discouraged because of this risk of skin maceration  5 Hirschsprung’s Disease aka “congenital analogion megacolon” It could genital anomaly present from birth which causes a lack of mobility peristalsis and intestine and can lead to an obstruction of the intestine basically their ganglion cells are missing which causes loss of function. Symptoms of Hirschsprung’s Disease Failure to pass meconium within 24-48 hours Bile-stained (yellow brown) vomitus Constipation Frequent foul-smelling ribbon-like or pellet stools Abdominal distention Palpable fecal mass Thin extremities Poor feeding Inadequate weight gain Diagnosis Abdominal x-ray Barium enema Rectal biopsy Treatment Removal of aganglionic portion of intestine Two step procedure Temporary colostomy Bowel excision of aganglionic portions & re-anastomosis normal bowel to anal canal when 8-10 kg Pre- Operative Care for a Hirschsprung’s Disease Provide bowel cleansing program as prescribed Observe for symptoms of bowel perforation such as 1. Abdominal distention (measure abdominal girth) 2. Vomiting 3. Increased abdominal tenderness 4. Irritability 5. Dyspnea and cyanosis 6. Begin teaching regarding colostomy Nursing Consideration for Hirschsprung’s Disease Hirschsprung can sometimes lead to a condition called enterocolitis, which is inflammation of the small intestines and colon. DO NOT take rectal temps in children with congenital megacolon.  6 Body Water Deficit & Dehydration Infant and young children are vulnerable to fluid, electrolyte, and acid-base imbalances. The percentage of body weight that is composed of water is highest at birth (higher in premature infants) and decreases with age. There is a high daily fluid requirement during infancy, the infant vulnerable to dehydration Signs of Fluid Volume Deficit 1. Heart rate – rapid, weak, thready Risk factors for Dehydration 2. Blood pressure – decreased Vomiting 3. Skin – poor elasticity, pallor, cool to touch, Diarrhea poor capillary refill, anterior fontanel sunken Pyloric stenosis 4. Mucous membranes – dry Malabsorption 5. Salivation &/or tearing – decreased Decreased fluid intake 6. Behavioral changes – lethargy, irritability 7. Sensorium changes - thirst Signs Of Dehydration 1. Loss of extracellular fluid & electrolytes 2. Classified according to the status of serum sodium concentration 3. Isonatremic (most common) 4. Hyponatremia 5. Hypernatremia 6. ***Dehydration can lead to shock – early recognition and treatment is essential to prevent progression to hypovolemic shock Severity of Dehydration Mild: Normal vital signs, fussy, restlessness, alert, thirsty, normal mucous membranes & skin turgor, anterior fontanel & eyes normal, capillary refill < 3 seconds – Up to 5% body weight lost which equates to 40-50 mL/kg Moderate: increased heart rate, normal to low blood pressure, lethargic but arousable, dry mucous membranes, decreased (poor) skin turgor, anterior fontanel sunken & eyes slightly sunken, capillary refill 3-5 sec, Specific gravity =1.020-1.030, urine output decreased, dark color – 6 – 10% body weight lost which equates to 60-90 mL/kg Severe: increase & weak heart rate, low blood pressure, rapid & deep, drowsy to comatose & not arousable, parched mucous membranes, very poor skin turgor, anterior fontanel sunken, eyes markedly sunken – no tears, capillary refill >5 sec, Specific gravity >1.030, urine output very decreased or absent – greater than 10% body weight lost which equates to 100 mL/kg ***Remember the more accurate way of measuring or describing dehydration is to report acute loss (over 48 hours or less) in milliliters per kilogram of body weight. Nursing Interventions & Expected Outcome for Dehydration Therapy Mild to moderate dehydration is treated with oral rehydration fluids first 5 to 15 mLs of fluid every 10 to 15 minutes is recommended for starting oral rehydration fluids Remember – small amounts at frequent intervals Maintains good skin turgor, retains integrity of skin surface & weight at usual level States relief from cramping & less or no diarrhea Achieves adequate nutritional intake to support growth and development Family acknowledges the importance of handwashing in decreasing transmission of infectious agents  7 Electronic fluid devices/volume-controlled devices are always used to deliver infusion therapy/intravenous fluids to pediatric patients because children are prone to fluid overload. Formula for daily fluid requirements: This formula will be provided on quiz. 0-10kg 100 ml/kg/day >10kg-20kg 1,000ml for first 10kg + 50 ml/kg/day for each additional kg over 10 > 20kg 1,500ml for first 20kg + 20ml/kg/day for each additional kg over 20 Take total amount & divide by 24 for hourly rate. This information will not be provided. You should know a day equals 24 hours. Examples: 0-10kg = 100 ml/kg/day Child weighs 5 kg 5kg=500ml/day divide by 24 = 20.8 or 21 mL/hr Child weighs 10kg 10kg=1000ml/day divide by 24 = 41.6 or 42 mL/hr >10kg-20kg = 1000ml first 10 kg + 50ml/kg for each kg Child weighs 15 kg 1000ml+50(5) =1250 divided by 24 = 52mL/hr Child weighs 20 kg 1000ml+50(10) =1500 divided by 24= 62.5 or 62mL/hr >20kg = 1500ml first 20kg + 20 ml/kg for each kg Child weighs 25 kg 1500ml + 20(5) =1600 divided by 24 = 66.6 or 67mL/hr Make sure you understand because you will be given a maintenance rate problem(s) on your quiz. You will be provided with the formula and the child’s weight. Practice your math problems here:  8 Vomiting & Diarrhea forceful expulsion of stomach contents Complications of Vomiting Metabolic alkalosis Dehydration Electrolyte imbalance Malnutrition Causes of Vomiting Allergic reaction Overfeeding Infection CNS disorders (projectile) Medications Pyloric stenosis (projectile) Intussusception Nursing Care for Patients who are Vomiting Mountain moderate dehydration result from vomiting withhold oral feedings from one to two hours after vomiting Give the infant or child 0.5 to 2 ounces of ORS every 15 minutes ask about how frequent the vomiting is Assess the child's past medical history to identify pre-existing illnesses such as drug abuse trauma and prescribed medications and previous abdominal surgery these are all risk factors for vomiting Note hydration status and mental status changes Palpate the abdomen Diarrhea Acute < 14 days and Chronic > 14 days Complications of Diarrhea Metabolic alkalosis, Dehydration Electrolyte imbalance, Malnutrition Causes of Diarrhea Infection (rotavirus most common) Parasitic infestation Associated with upper respiratory illness (URI), urinary tract illness (UTI), Otitis Media (OM) Diet Medications Toxic ingestion Irritable bowel syndrome Treatment & Interventions for Diarrhea Rehydration therapy Oral rehydration solutions such as Pedialyte IV fluids check for kidney functioning before adding potassium chloride (KCL) to primary IV fluids Weight is an important determinant of percent of total body loss in infants and children Check capillary refill on infant’s sternum  9 Oral Candidiasis (Thrush) – pages 677-678 Fungal infection of the oral mucosa, most common in newborns and infants. Causes & Risk of Oral Candidiasis Immune disorders Children using corticosteroid inhalers Any type of therapy that suppresses the immune system Symptoms of Oral Candidiasis Thick white patches in the infant with oral candidiasis (thrush). These patches do not wipe off with washcloth or swab. Treatment for Oral Candidiasis Oral antifungal agents such as Nystatin or fluconazole Pyloric Stenosis Hypertrophy of the circular muscle of the pylorus causing narrowing between stomach & duodenum Diagnosis Ultrasonography / Upper GI series Symptoms Projectile vomiting (stomach contents may eject up to 3 feet from the infant) visible peristaltic waves from left to right across the epigastrium. failure to thrive/weight loss Olive-shaped mass in right upper quadrant Elevated hemoconcentration and BUN Non-bilious emesis (white in color) (metabolic alkalosis) Treatment laparoscopic pyloromyotomy surgery – prognosis is good Nursing Interventions & Care for Pyloric Stenosis Maintain IV hydration Provide small, frequent oral feedings or glucose or electrolyte solutions or both within 4 to 6 hours Gradually increase to full-strength formula Position infant on right side in semi-Fowler position after feeding ***Key problems for children with GI disorders are nutritional needs and fluid and electrolyte balance. Younger children have a need for increased caloric intake required for growth, therefore, are more vulnerable to fluid and electrolyte imbalances.  10 Intussusception – pages 679-680 one part of the bowel into another part of bowel causing obstruction (rectal bleeding) Symptoms Currant jelly-like stool bloody Palpable sausage shaped abdominal mass Lethargy Diagnosis Abdominal x-ray Barium enema Treatment Contrast (barium) Air or liquid enema May resolve on its own Surgery ***Conditions such as cystic fibrosis, Henoch-Schonlein purpura, Crohn disease and, celiac disease can increase the risk of intussusception. Appendicitis pages 681-682 Most common condition requiring abdominal surgery in pediatric population Symptoms Periumbilical pain followed by right lower quadrant pain Nursing Assessment Remember to test for rebound tenderness Treatment Appendectomy surgery is always indicated for cure  11 Gastroesophageal Reflux – pages 682-685 Gastric content reflux into lower esophagus results in tissue inflammation, scarring, & stricture Symptoms Chronic vomiting Hematemesis (bloody stools0 Failure to thrive (FTT) Abdominal pain irritability Nursing Interventions Medications (fundoplication), Thickened feedings (smaller feeding volume at more frequent intervals) Position prone with head elevated for 1-2 hours after feeding Cardiorespiratory monitor Treatment Surgery: Nissen fundoplication (creation of a valve mechanism) with g-tube for 6 weeks post- op Diagnosis Barium swallow & Upper GI Endoscopy Medications Antacids Neutralize acidity Histamine blockers: Ranitidine Decrease gastric acid production (Zantac), Cimetidine (Tagamet) Metoclopramide (Reglan) Increase esophageal motility & tone Cisapride (Propulsid) Increase esophageal motility & tone  12 Inflammatory Bowel Disease – pages 690-692 Crohn’s disease – chronic inflammatory process Symptoms Diagnostic u Abdominal pain with cramps u Diarrhea u CBC – anemia and increased white blood cells (WBCs) u Weight loss u Erythrocyte sedimentation rate (ESR) – increased u Anorexia u C-reactive protein - elevated u Fever (may be present) u Protein, albumin, iron, zinc, magnesium, vitamin B12 – u Rectal bleeding and perineal low discomfort u Stools for blood, leukocytes, and infectious organisms u Upper GI series u CT scan u Barium enema u Colonoscopy with biopsy Medications Pharmacological Antidiarrheal preparations; Anti-inflammatory agents; Immunosuppressants; Analgesics – narcotics; Antibiotics Nutritional – controlling the disease by remission & preventing relapses all by maintaining adequate nutrition - Dietary modifications; Vitamins; Oral supplements; Hyperalimentation Surgical - 70% of these patients require surgery to drain abscesses, close fistulas, remove short segments of diseased bowel, repair perforations, relieve obstructions, or widen strictures – surgery is not curative – palliative - (improve quality of life and relieve symptoms) Ulcerative colitis chronic recurrent disease – acute and chronic inflammation, bloody diarrhea, curable with surgery Signs & Symptoms Abdominal pain bloody diarrhea urgency tenesmus Treatment Pharmacological, nutritional, surgical, and psychosocial management Curable with surgery ileostomy  13 Necrotizing Enterocolitis this is a potentially life-threatening inflammatory disease of the intestinal tract occurring primarily in premature infants Symptoms Manifestations usually occur during the second week of life after enteral feedings are started, however if can occur anytime and even several weeks after feedings have begun. May initially shows signs of feeding intolerance, increased gastric residuals, vomiting, irritability, and abdominal distention – bloody diarrhea may be present. Condition will process to lethargy, periods of apnea and bradycardia, and temperature instability. Requires immediate intervention to decrease morbidity and mortality Celiac Disease – pages 692-693 “Gluten Intolerance” Results for the inability to digest protein of wheat, barley, rye, and oats, life-long deficiency, requires life-long diet modification (nurse may refer to nutritionist), the child must maintain a gluten-free diet, parents and children must learn to read labels, again concern about growth failure Symptoms Early signs: diarrhea, vomiting, failure to gain weight, constipation, abdominal pain, steatorrhea (foul smelling, pale, fatty stools) Later signs: behavior changes (irritable or apathy), muscle wasting with loss of subcutaneous fat Celiac crisis: electrolyte imbalance, dehydration, severe acidosis Diagnosis 72-hour fecal fat analysis, jejunal biopsy reveals atrophy of mucosal cells, serum antigliadin & antireticulin antibodies Treatment Gluten-free diet (corn, rice, or millet for grain) & eliminate wheat, rye, oats, & barley; vitamins ADEK; steroids for celiac crisis Diet for Celiac Disease High calories and proteins Simple carbohydrates, fruits and vegetables, and low in fats Avoid High fiber foods (nuts, raisins, raw vegetables and raw fruit with skin) slowly introduce.  14 Viral Hepatitis – pages 693-698 May be acute or chronic and involves an inflammation of the liver. Caused by virus or bacterial infections, fungal or parasitic infections, or chemical or drug toxicity Liver function tests – specifically elevation of ALT, AST and serum total bilirubin Hepatitis A is the most common type found in children Fecal-oral route is primarily how Hepatitis A occurs Is highly contagious – transferred by direct person – to – person spread or through ingestion of contaminated water or food It is a common cause of foodborne illness Most children recover without lingering problems Vaccine available – two (2) doses at least six (6) months apart – first dose is recommended at age 12 months (1 year) Colic – page 89 Usually described as a feeding disorder characterized by paroxysmal abdominal pain and severe crying Crying can last up to 3 hours and occur as frequently as 3 times a week These episodes peak around 6 weeks of age and usually resolve by 3-4 months of age Etiology is unknown Failure to Thrive Syndrome in which infants or young children fail to eat enough nutrients to be adequately nourished Etiology can be organic as in acquired immunodeficiency syndrome, inborn errors of metabolism, esophageal reflux, and possible neurological disease However, most are not organic in nature Overweight and Obesity – common problems in the pediatric population, puts children at risk for developing health issues as they age – diet modification and exercise are the recommendations to help loss weight in the pediatric population Anorexia Nervosa – Review etiology and pathophysiology and clinical manifestations along with nursing management for child with anorexia nervosa In adolescents with anorexia nervosa most likely experienced amnio hypothermia low blood pressure and bradycardia the nurse would also note soft hair on the individual's back and arms Symptoms to look at with children with any anorexia nervosa Aim for weight gain goal of 0.5 to 2 lbs per week Give phosphorus supplements Assess vital signs frequently for orthostatic hypotension irregular and decreased pulse and hyperthermia  15 Ingestion of Poisons Lead poisoning excessive level / accumulation of lead in blood Causes of lead poisoning Food Air Water Dust Soil contaminated with lead Loose paint chips Inhalation or ingestion through placenta Preventions for lead poisoning Universal screening for children 1 to 2 years Earlier for children at risk – any child between 3 to 6 years who has not been screened Perform risk assessment and if positive, screen at 6, 9, 12, 18, and 24 months and at 3, 4, 5, and 6 years Treatment for Lead poisoning Chelation therapy removes lead from blood and from some organs & tissues – this therapy does not counteract effects of lead poisoning – medication is excreted via kidneys provide good hydration and monitor kidney functioning for nephrotoxicity (MONITOR CHILD’S RENAL FUNCTION & CBC WHILE RECEIVING CHELATION THERAPY!!!!!! General Poison Prevention & Care Common household products poisonous to children Perfume, Aftershave, sunburn relief products, alcohol, cigarettes or any type of tobacco products mouthwash. ****Call poison control at 800-222-1222 if you think a child has been poisoned but they are awake and alert. If you suspect poisoning and the child has collapsed or is not breathing call 911. An empty stomach absorbs more lead; hot water can contain higher levels of lead because it dissolves lead more quickly than cold water – so only on use cold water for drinking, cooking, and especially when mixing infant formula. u Acetaminophen – toxic dose is 150 mg/kg or higher in children – treatment activated charcoal if ingestion to treatment time is less than 4 hours v Antidote - N-Acetylcysteine (oral or intravenously) – Be sure to dilute oral antidote in juice or soda v Also, when using activated charcoal with lavage, do not give administer N-Acetylcysteine – activated charcoal inactivates N-Acetylcysteine u Aspirin – 100 mg/kg per day for 2 days or more, severe toxicity 300 to 500 mg/kg – activated charcoal to decrease absorption of salicylate – meds to induce vomiting may be prescribed, watch for bleeding might need Vitamin K, also monitor for seizures might need anticonvulsants u Corrosives – should as bleach, detergents (Tide pods), household cleaners, paint or paint thinner, batteries (small button batteries) v Treatment – dilute corrosive with water or milk (4 oz. [120 mL]) – do not induce vomiting  16 Genitourinary Conditions: Chapter 21: Nursing Care of the Child with an Alteration in Urinary Elimination/ Genitourinary Function ***Remember the only way to collect sterile urine is via catheterization! Immature kidney functioning – (infants are more prone to fluid overload) HESI Hint: One of the first signs of renal failure is decreased urinary output. Urinary output for infants and children should be 1 to 2 mL/kg/hr. Bladder Exstrophy – pages 713-714 Bladder is open and exposed outside of the abdomen Treatment for Bladder Exstrophy Surgical repair upon physical exam the bladder is red in appearance and can be seen on the abdominal – draining urine is visible – review notes and text Postoperative Care after Bladder Exstrophy surgery Protect the bladder by preventing infection Keep the infant in supine position Keep the bladder moist and cover it with a sterile plastic bag change soil diapers immediately to prevent contamination of the bladder with feces Prevent breakdown of skin by applying protective barrier creams Vesicoureteral Reflux – pages 717-718 Usually congenital abnormality, two contributing factors to UTIs – bacteria in the urine can be carried up to the kidney and cause pyelonephritis and renal damage or urine that has refluxed into the ureter can return to the bladder and leave urine residual which is a medium for bacterial growth. How to Treat Vesicoureteral Reflux Treatment is based on Grade I-V Grade I-III no surgery only prophylactic antibiotic therapy Febrile children: monitored & screened every few months or as needed. Grade IV and V require surgical intervention to reimplant the ureters into the bladder. This child would need to be on prophylactic antibiotics and might need antispasmodics.  17 Urinary Tract Infections (UTIs) – pages 719-720 bacteria in the urine along with signs and symptoms of infection. Most common cause is E. coli. Fever without focus is suggestive of UTI. Young girls are prone to UTIs because of short urethra remember no bubble baths, etc. Should always test for cure after treatment for UTI. UTI in Infants Fever, Irritability, Dysuria, Crying when voiding Change in urine color, odor, poor weight gain, feeding difficulties UTI in Children Abdominal pain, Urinary frequency, Dysuria, Fever Pyelonephritis Exhibit same symptoms of UTI Back pain CAV tenderness nausea and vomiting they also appear very ill ***Treatment for UTIs requires antibiotic therapy for 7 to 10 days (IV antibiotics for pyelonephritis followed by oral therapy). Nephrotic Syndrome – pages 722-724 Know this is a kidney disorder characterized by proteinuria, hypoalbuminemia, and edema. Two types primary and secondary. Symptoms of Nephrotic Syndrome Edema, anorexia, fatigue, abdominal pain, increased weight gain. Treatment for Nephrotic Syndrome Prednisone 2mg/kg/day two or three times a day until zero trace of protein in the urine for 5 to 7 days, steroids must be tapered before discontinuing, and these children must adhere to a no-added-salt diet. Acute Poststreptococcal Glomerulonephritis – pages 724-725 Self-limiting, occurs suddenly, and resolve completely. Most common is post streptococcal glomerulonephritis which follows a strep infection. Symptoms Hematuria #1 sign Proteinuria, edema, renal insufficiency, and HYPERTENSION!!! Treatment for Glomerulonephritis Bedrest, monitor fluid and electrolyte, monitor intake and output, daily weights, fluid restrictions may be ordered, sodium, potassium, and protein may be limited, no medication unless strep has not been completely treated or symptoms such as hypertension needs medication. These children appear sick and need a lot of support.  18 Hemolytic Uremic Syndrome – pages 725-726 Most common cause of renal failure in children, usually caused by ingesting beef contaminated with E. coli, potentially lethal outcome causes acute renal failure Cryptorchidism (undescended testes) – page 738 usually detected during newborn examination – in most of the cases, the testes descend spontaneously by 3 months of age, if testes do not descend spontaneously, an orchiopexy is performed around 12 months of age to prevent further testicular damage. Also, the risk of testicular cancer is higher in men with a history of cryptorchidism. Musculoskeletal Conditions: Chapter 22: Nursing Care of the Child with an Alteration in Mobility/Neuromuscular or Musculoskeletal Disorder Review PowerPoint and class lecture notes plus complete readings Pediatric Differences n Growth occurs at the epiphyseal plate until adult height is reached (stimulated by Pituitary GH) n Growth velocity n 2.54 cm/month in first 6 months n 1.27cm/month in second 6 months 7.6 cm/year from ages 1-7 years n 5 cm/year from ages 8-15 years n Sutures of the cranium do not fuse completely until age 18 months n Bones are more pliable & porous in children resulting in bend or buckle n Soft tissues are more resilient & bone healing is more rapid in children than in adults Compartment syndrome A progressive decrease of tissue perfusion occurring because of increased pressure from edema or swelling. Circulation is affected from cast being waaaay too tight! Compartment syndrome can lead to Permanent nerve and vasculature damage, possibly leading to amputation of the limb. Compartment syndrome Treatment Fasciotomy – a surgical procedure where the fascia is cut to relieve tension or pressure to treat the loss of circulation to an area – it is the limb-saving procedure when used to treat acute compartment syndrome. Casting pages 746-747, 755-759 Purpose: to immobilize the fracture site & involve joints above & below the fracture Cast Care n A wet cast should be handled by the palms of the hands to prevent indenting the cast & creating pressure areas n No hot spots should be felt; nothing inside cast n Check for swelling in first 6-8 hours; Elevate; protect from water & urine n Type: Plaster of Paris (drying takes 24-48 hours) & Synthetic  19 Physical Examination of Compartment Syndrome n Inspection: alignment, symmetry, skin color, ecchymosis, swelling n Palpation: muscle tone, heat, tenderness, swelling, pain, crepitus, nodules, masses n Joint range of motion n Muscle strength n Five P's of vascular impairment n Pain & joint tenderness n Pallor n Pulselessness distal to the fracture site n Paresthesia distal to the fracture site n Paralysis Neurovascular checks for the involved extremity include: the child's sensation to touch, temperature, movement, strength of the pulse, and capillary refill time in the extremity distal to the injury. Traction pages 759-762 Why use Traction? 1) To fatigue the involved muscle & reduce muscle spasm so bones can be realigned 2) To position the distal & proximal bone ends in desired realignment to promote satisfactory bone healing (reduction) 3) To immobilize the fracture site until realignment & healing to permit casting or splinting Types of Traction - Table 22.1 pages 760-761; Also, refer to PowerPoint Presentation Manual – applied to the body part by hand & placed distally to the fracture site; often performed during cast application Skin – pull is applied directly to the skin surface & indirectly to the skeletal structures; pulling mechanism is attached to skin with adhesive material or an elastic bandage. DO NOT REMOVE unless Provider ordered. Skeletal – pull is applied directly to the skeletal structure by a pin, wire, or tongs inserted into or through the diameter of the bone distal to the fracture. Pin sites source of infection, so monitor for signs of infection. Weights with Traction n Weights must be hanging freely n have someone hold the weights when you reposition the child in the bed n Person must also know to gently let go of the weights slowly after the correct position has been obtained.  20 Neural Tube Defects – pages 763-767 Myelomeningocele or Spina Bifida. Prevention of Neural Tube Defects – FOLIC ACID intake for all childbearing age women. Care for all Neural Tube Defects n Turning and repositioning every 2 hours n Assessing the skin for redness or breakdown n Performing range-of-motion exercises n Keeping the skin clean and dry n Encouraging intake of fluids to maintain hydration status n Encouraging coughing and deep breathing every 2 hours and as needed Spina Bifida Pre surgery Care (usually performed 48 hours after birth) n Position on side or abdomen with gentle handling n Keep sac moist with sterile, saline-soaked dressings n Avoid contamination of sac by urine or feces n Avoid rectal temp n Encourage parent bonding Spina Bifida Post Surgery Care n Assess neuro status n Monitor Intake / Output n Monitor incision site n Discharge education INFANTS with Neural Tubal Defects (except those with spina bifida occulta) have n Neurogenic bladder, frequent, clean straight catheterization is preferred management and teaching this to parents is important. n Neurogenic Bowel - Teach the family to develop a bowel management plan using control of high-fiber diet, adequate fluid intake and pattern for evacuation of bowels, in some cases medical providers prescribe laxatives and enemas. n Latex Allergies they develop latex allergies due to the frequent exposure to latex during catheterizations and multiple operations. n Measure head circumference because there is a high risk for hydrocephalus, in fact hydrocephalus is usually present in children with a myelomeningocele defect. n Instruct family on signs/symptoms of increased intracranial pressure and what to do if symptoms occur. ***Any child that presents with hydrocephalus will present with symptoms such as bulging fontanelle rapid head growth prominent scalp veins irritability vomiting seizures poor feeding lethargy high pitched cry eyes deviated downward and strabismus if the child presents with this teach parents to seek medical attention most likely the doctor will order imaging such as ultrasound or CT scan to diagnose hydrocephalus.  21 Developmental Dysplasia of the Hip (DDH) – pages 772-774 Previously known as congenital hip dysplasia (CHD) & congenital dislocation of the hip (CDH) Three Degrees of DDH Acetabular dysplasia (or preluxation) – mildest form, no subluxation or dislocation Subluxation – incomplete dislocation of the hip Dislocation – femoral head loses contact with the acetabulum, hip rests in a dislocated position Assessment of DDH Diagnosis should be made during the neonatal period; treatment initiated before 2 months of age is most successful Hip examination needs to be included as part of the health examination until the child begins to walk Clinical Manifestations – Infant with DDH n Shortening of the limb on the affected side n Unequal gluteal folds (prone position) n Restricted abduction of hip on affected side n Positive Ortolani test – down and outward movement of the hips to hear clicking sound n Positive Barlow test - upward and inside movement of hip to hear clicking sound Clinical Manifestations – Toddlers and Older Children n Waddling gait n Marked lordosis when standing n Affected leg shorter than other leg n Presence of Trendelenburg sign Positive Trendelenburg usually indicates weakness in the hip abductor muscles gluteus medius and gluteus minimus. Diagnostic Tests for DDH – Ultrasonography - infants 4 months and younger – Radiographic examination – infants older than 4 months Medical Management of DDH Treatment varies depending on the severity of the symptoms, the extent of the dysplasia, and the infant’s age. Greater chance a normal hip will develop if dislocation is corrected during the first days of life During neonatal period, a corrective device is placed to maintain the hip in flexion and abduction Wear the harness for 24 hours a day Monitor for redness irritation and skin breakdown Place baby on their back to sleep gently massage the skin under their strap to promote circulation  22 Cerebral palsy (CP) – pages 782-787 (a nonprogressive motor disorder of the central nervous system resulting in alteration in movement and posture. Cerebral Palsy one of the leading causes is anoxia or hypoxia at birth. Signs & Symptoms of Cerebral Palsy Primitive reflexes delayed gross development Lack of progression through the developmental milestones Abnormal posturing with inability to maintain normal posture and balance Spasticity or uncontrollable movements in the extremities Struggling in gait, seizures, attentive deficit disorder, sensory impairment, failure of automatic reactions (equilibrium), and speech and swallowing impairments. RISK FOR ASPIRATION ***Preventing aspiration when feeding an infant or child with CP such as positioning the child upright and supporting the lower jaw. Legg-Calvé-Perthes Disease – pages 788-789 a self-limiting condition involving avascular necrosis of the femoral head – unknown etiology – interruption of the blood supply to the femoral head results in bone death and the spherical shape of the femoral head losing its shape Swelling of the soft tissue around the hip occurs – revascularization occurs but takes 18 to 24 months and during the time the bone is soft and more likely to fracture, however, over time the femoral head reforms. Children with Legg-Calvé-Perthes Disease should avoid contact or high impact sports (swimming and biking will help maintain range of motion) – review information in text Scoliosis – pages789-793 Signs of Scoliosis – Lateral curvature of the spine of more than 10 degrees – Can occur anywhere along the spine – thoracic area is the most common – Most common spinal deformity – Can be congenital, develop during infancy or childhood, but most seen in early adolescence – called idiopathic scoliosis Diagnostic Tests – Forward bending test – screening test – X-ray of the spine – anteroposterior and lateral – Medical Management of Scoliosis – Monitored closely every 3 to 12 months is curve is less than 20 degrees – If curvature 20 to 40 degrees, bracing is usually considered along with exercise – Surgery may be considered for severe cases  23 Osteomyelitis – pages 445-446 Infectious process of the bone – Can occur at any age. Most commonly between 5 to 14 years – Most seen in boys Clinical Manifestations of Osteomyelitis – Fever – Abrupt pain – point tenderness above the bone and swelling and warmth over the bone –Unwillingness to bear weight or to move limb – Irritability – Possible dehydration/poor appetite Result from a penetrating injury or wound Infection elsewhere in the body that has traveled to the bone Also follow an upper respiratory infection. Medical Management of Osteomyelitis – Intravenous (IV) antibiotics usually for 4 to 6 weeks – Bed rest – Affected limb may be immobilized in a cast or splint – Surgery may be performed Integumentary Conditions: Chapter 23: Nursing Care of the Child with an Alteration in Tissue Integrity/Integumentary Disorder Less subcutaneous fat, thinner skin, loss of heat. Impetigo (bacterial Infection)– page 813 Highly contagious bacterial infection Staphylococcus aureus and Streptococcus pyogenes or both Signs & symptoms: lesion starts as a vesicle or pustule with edema and erythema – later the lesions erupt, leaving honey-colored exudate Exudate is crusty in appearance and sticky to touch Treatment & Prevention for Impetigo Good handwashing for prevention keep infants’ nails trim and short Mittens for infant hands to prevent scratching Instruct parents to remove crust from lesions before applying topical medication Severe cases require systemic antibiotics  24 Cellulitis – pages 813-815 This is a bacterial infection that enters the body via existent openings in the skin caused by dermatological conditions or trauma Most common bacteria Staphylococcus aureus and Streptococcus pyogenes Signs and symptoms of Cellulitis Edematous, erythematous, warm or hot to touch, pain at affect area Treatment for Cellulitis Mild, oral antibiotics Severe cases need hospitalization and intravenous medications Require incision & drainage (I & D). Fungal Infections – pages 815-817 Treatment of Fungal Infections *Applying antifungal creams, lotions, ointments you want to apply with thin layer and rub into the outside of the affected area first and then rub inward. Starting inside and working outward will help spread the fungal infection not improve. Clean area before applying topical antifungals. Dermatitis Diaper Dermatitis – rash from diaper Treatment for Diaper Dermatitis Change diaper frequently Avoid rubber pants, baby wipes with fragrance Allow infant to be diaper less Blow dry diaper area Atopic Dermatitis – pages 818-820 – refer to PowerPoint and reading from text Treatment Aquifer if bacteria antibiotics Contact Dermatitis Allery, poison ivy, oak, sumac, nickel, dyes, substance exposure. Contact Dermatitis Complications pf Contact Dermatitis Bacterial kin infections such as lichenification & hyperpigmentation Treatment of Contact Dermatitis Topical corticosteroid 7-10 days Seborrhea – page 823 Cradle cap infants – face Treatment for Seborrhea Daily shampooing, applying emollient (soothes and softens) Remove the scales by brushing with fingertips or a soft toothbrush  25 Burns – pages 827-835 Treatment Goals for Burns Decreasing burn fluid losses Preventing infection #1 Concern Must maintain asepsis when delivering care – these patients are often on protective isolation precautions. Controlling pain Promoting nutrition Burns Wound Care 1)Remove necrotic tissue and speed wound debridement MEDICATE CHILD 30-45 minutes before!!! 2) Maintain moist wound conditions and adequate circulation – usually an antibacterial/antimicrobial medication or dressing is applied. 3) Use active and passive range of motion to maintain and restore joint flexibility 4) Conserve body head and fluids – MONITOR strict intake and output 5) Protect from infection – Maintain reverse isolation and strict asepsis with wound care and dressing changes 6) Control scarring and prevent scar contracture: Educate patient and family, moisturizing creams may be used after the burn has healed completely helps with drying, remember healed skin is super sensitive to sunburn, keep area cover or use sunscreen, prevents hyperpigmentation after burn healing. Pediculosis – Table 15.6 “Common Parasitic Infection in Children” – pages 458-459 Itching is only symptoms – Treatment rid hair of “nits” Scabies – Table 15.6 “Common Parasitic Infection in Children” – pages 458- 459 Symptoms Intense itching is present Treatment Elimite cream or lotion Clean all clothing, bedding, towels, cloth toys, hair items by washing in hot water and placing in dryer Animal Bites n Never provoke a dog with teasing or roughhousing n Get adult permission before interacting with a dog, cat, or other animal that is not your pet n Do not bother an eating, sleeping, or nursing dog n Avoid high-pitched talking or screaming around dogs n Display a closed fist first for the dog to sniff n Keep ferrets away from the face n If a cat hisses or lashes out with the paw, leave it alone