Peds Exam 3- Hematology/Blood Disorders in Children PDF

Exam 3 --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------...

Exam 3 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -- **Hematology/Blood Disorders in Children (Chapter 24)** **Iron Deficiency Anemia**: Know the S/S associated with this type of anemia and the management. Review education to give parents about iron supplementation. Review prevention measures and treatment recommendations (class power-point, p. 786-788) Therapeutic and Nursing Care Management) **Sickle Cell Anemia**: Recognize the differences between sickle cell trait and sickle cell anemia. Recognize signs/symptoms of a crisis and appropriate nursing interventions. Recognize the different types of crises that can occur in sickle cell anemia and their symptoms: vasoocclusive, sequestration, acute chest syndrome, infarctions. (class power-point, p 788-797 Box 24.2, p. 790) **Beta Thalassemia (Cooley anemia) & Aplastic Anemia:** Know the pathophysiology, manifestations, and nursing care with these (class power point, p. 797-799). **Blood-Transfusions:** Recognize signs and symptoms of a hemolytic transfusion reaction. What are the priority nursing interventions in this situation? (class power-point, table 24.3 p 809-810; p 809-811) **Hemophilia**: Understand the disease process, the most common type, which factor is involved, complications, treatment measures for a child with bleeding, and how to prevent the crippling effects of bleeding (class power-point, p. 799-802) **Von Willebrand Disease**: Recognize characteristics of this disorder, and teaching education to give. (class power-point, p. 799-802) **Immune Thrombocytopenia:** Affected labs, s/s, treatment, and reason/considerations for splenectomy also with regards to immunizations prior to splenectomy (class power-point, p. 802-804). **Disseminated Intravascular Coagulation (DIC):** Know the phases of DIC, when to suspect it and what to watch for, and the management (class power-point, p 804). **Epistaxis:** Management and emergency treatment involved (class power-point, p 804-805). **Childhood Cancers (Chapter 25)** **Leukemia**: Recognize signs/symptoms of leukemia and how common it is in children. Recognize what lab values would look like in a child who has leukemia. (class power-point, p. 830-833) **Lymphoma**: Recognize signs/symptoms of lymphoma. Recognize the difference between Hodgkin vs. Non-Hodgkin Lymphoma. (class power-point, p. 833-836) **Neuroblastoma:** Know where it arises, "silent tumor", manifestations (class power-point, p 841-842). **Rhabdomyosarcoma & Retinoblastoma:** Know what type of cancer these are, s/s seen with each, and the treatment and emotional support given/home care (class power-point, p. 846-849) **Bone Tumors**: Recognize the signs/symptoms of osteosarcoma and Ewings sarcoma. Recognize the differences between them. Age groups involved. Phantom limb pain. (class power-point, p. 842-844) **Wilm's Tumor**: Recognize signs/symptoms of Wilm's Tumor. (class power-point, p. 844-846) **Cancer Nursing Care:** Recognize nursing care and teaching related to: alopecia, tumor lysis syndrome, nausea and vomiting, neurotoxicity, superior vena cava syndrome, spinal cord compression, DIC, hyperleukocytosis. Also, effects with infection, hemorrhage, anemia, altered nutrition, mucosal ulcerations, neurologic problems, hemorrhage cystitis, and steroid effects (class power-points and p. 823-828) **Cancer:** Labs, diagnostics, risk factors, S/S of cancer in children, and management of side effects of treatment (class power-points and p. 817-830). ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -- +-----------------------------------+-----------------------------------+ | **Genitourinary Disorders | | | (Chapter 26)** | | +-----------------------------------+-----------------------------------+ | **Urinary Tract Infections:** | | | Recognize the findings on | | | urinalysis that indicate UTI. | | | Recognize risk factors for UTI in | | | children and caregiver education | | | to prevent incidence. (class | | | power-point, p. 855-861, Box 26.1 | | | p. 861 TTC \#4) | | +-----------------------------------+-----------------------------------+ | **Vesicoureteral Reflux:** | | | Recognize this condition, and how | | | it contributes to UTIs in | | | children (class power-point, p. | | | 861-863, TTC \#4) | | +-----------------------------------+-----------------------------------+ | **Hemolytic Uremic Syndrome:** | | | Recognize what this condition is | | | and common pathogens that cause | | | it. Recognize nursing | | | interventions for management. | | | (class power-point, p. 872-873, | | | TTC \#4) | | +-----------------------------------+-----------------------------------+ | **Phimosis/Hydrocele/Hypospadias/ | | | Epispadias/Cryptorchidism:** | | | Be able to distinguish between | | | these conditions, how each one is | | | treated, and caregiver education | | | (class power-point, p. 863-867) | | +-----------------------------------+-----------------------------------+ | **Glomerulonephritis:** Recognize | | | what this condition is and | | | nursing interventions related to | | | treatment. (class power-point, p. | | | 871-872) | | +-----------------------------------+-----------------------------------+ | **Nephrotic Syndrome:** Recognize | | | symptoms of this condition, and | | | how it differs from | | | glomerulonephritis. Recognize | | | nursing interventions for | | | management. (class power-point, | | | 868-871) | | +-----------------------------------+-----------------------------------+ | **Renal Failure:** Acute Kidney | | | Injury | | | features/management/complications | | |. | | | Chronic Kidney Disease | | | pathophysiology and nursing care | | | including dialysis and | | | transplantation (class | | | power-point, p. 873-880) | | +-----------------------------------+-----------------------------------+ | **Gastrointestinal Disorders | | | (Chapter 22) approx 12-14 | | | Points** | | +-----------------------------------+-----------------------------------+ | **Diarrhea and dehydration:** | | | Recognize the different physical | | | assessment findings/types/degrees | | | in both dehydration and diarrhea | | | and the nursing management of | | | each one. Know how to evaluate | | | dehydration and recognize the | | | manifestations (Table 22.3 & | | | 22.4) Know the infectious causes | | | of acute diarrhea (table 22.5) | | | What age range is at highest risk | | | with these? Know about water | | | intoxication (class power-point, | | | p 680-694). | | +-----------------------------------+-----------------------------------+ | **Fluid and electrolyte | | | Balances/Constipation/Vomiting** | | | | | | Recognize disturbances of Fluid | | | and Electrolyte Balance (Table | | | 22.2). Also know how constipation | | | and vomiting affect the pediatric | | | population (class power-point, p. | | | 694-698). | | +-----------------------------------+-----------------------------------+ | **Celiac Disease:** Know the | | | manifestations, evaluation, and | | | dietary education to give to | | | kids/parents (class power point, | | | p. 715-716) | | +-----------------------------------+-----------------------------------+ | **Short Bowel Syndrome:** Know | | | what kind of disorder this is, | | | nutritional support, and home | | | care to provide (P. 716-717). | | | Also know malrotation and | | | volvulus and how short bowel | | | syndrome is a complication (class | | | power-points, p 714-715). | | +-----------------------------------+-----------------------------------+ | **Hirschsprung\'s Disease**: | | | Recognize what this condition is | | | and the treatment (class | | | power-point, p. 698-699) | | +-----------------------------------+-----------------------------------+ | **Intussusception:** Know that | | | this is a potentially | | | life-threatening condition and | | | the pathophysiology. Recognize | | | signs/symptoms, evaluation, and | | | treatment of this condition. | | | (class power-point, p. 713-714) | | +-----------------------------------+-----------------------------------+ | **Pyloric Stenosis:** Recognize | | | signs/symptoms, know the cause, | | | and treatment of this disorder. | | | (class power-point, p. 712-713) | | +-----------------------------------+-----------------------------------+ | **Appendicitis:** Recognize | | | signs/symptoms and treatment. | | | Know the signs seen with | | | peritonitis and the care and | | | prognosis with a ruptured | | | appendix (class power-point, p. | | | 702-704) | | +-----------------------------------+-----------------------------------+ | **Med Dose Calculations** | | +-----------------------------------+-----------------------------------+ **[PODCAST LINK:]** [[https://notebooklm.google.com/notebook/71d66d1c-88ad-4312-b0eb-49f1f6d817bc/audio]](https://notebooklm.google.com/notebook/71d66d1c-88ad-4312-b0eb-49f1f6d817bc/audio) **Hematology/Blood Disorders in Children (Chapter 24** **Iron Deficiency Anemia:** Know the S/S associated with this type of anemia and the management. Review education to give parents about iron supplementation. Review prevention measures and treatment recommendations (class power-point, p. 786-788) Therapeutic and Nursing Care Management) - **S/S:** Pallor, fatigue, irritability, tachycardia, growth delays. - **Management:** Iron supplementation (oral or IV), dietary modifications (iron-rich foods), follow-up labs. - **Parent Education:** Give iron between meals, with vitamin C to enhance absorption, avoid giving with dairy. - **Prevention & Treatment:** Screen at-risk populations, encourage breastfeeding with iron-fortified formula, delay cow\'s milk until 12 months, iron-rich diet. Premature infants are more susceptible, occurring around 4-6 months -- use Fe supplements **Sickle Cell Anemia:** Recognize the differences between sickle cell trait and sickle cell anemia. Recognize signs/symptoms of a crisis and appropriate nursing interventions. Recognize the different types of crises that can occur in sickle cell anemia and their symptoms: vasoocclusive, sequestration, acute chest syndrome, infarctions. (class power-point, p 788-797 Box 24.2, p. 790) - **Sickle Cell Trait vs. Anemia:** Trait is carrier state (both parents have to have trait= 25% chance of having the disease); anemia involves disease symptoms (pain, fatigue, swelling). [Abn sickling of RBCs is caused by an abn Hemoglobin S (HgS)] - **Crisis S/S:** Pain, fever, tissue damage (RBCs are sickle-shaped) - **Types of Crises:** - **Vasoocclusive:** Pain due to blocked vessels. - Treatment involves managing pain, IV fluids, [heat] to the area (cold causes vasoconstriction), bed rest to help decrease O2 consumption, blood, monitor for shock, O2 for hypoxia, blood transfusions. - **Sequestration:** Splenic trapping of blood, severe anemia. - (blood gets stuck in the spleen causing splenic enlargement and is LIFE THREATENING) - Packed RBC's recommended -- to minimize chance of circulatory overload. - **Acute Chest Syndrome:** Respiratory distress, chest pain. - treat with antibiotics, fluids, incentive spirometer, O2 (but may not help if not enough cells carrying oxygen) - **Aplastic Crisis** -- decreased RBC production, usually after viral infection -- life threatening anemia. s/s pale/listless, dizzy/passing out, headaches. - **Infarctions:** Organ damage. Causes stasis of blood, ischemia and scarring of tissues. **Nursing Interventions:** Hydration, pain management, oxygen therapy, blood transfusions, antibiotics for infection. **Beta Thalassemia (Cooley anemia) & Aplastic Anemia:** Know the pathophysiology, manifestations, and nursing care with these (class power point, p. 797-799). - **Pathophysiology:** - **Beta Thalassemia:** Defective hemoglobin production due to destruction of RBC. - **Therapy:** - [Blood transfusion (hallmark management)] - maintain good Hbg levels (\>9.5) and provide adequate RBC's. - [iron chelation therapy] to prevent iron overload - (Complication is iron overload ([hemosiderosis])) - Fe+ can cause heart dysrhythmias - **Aplastic Anemia:** Bone marrow failure to produce blood cells. Low WBC, low platelets, anemia- at least two of the three are present. Happens as a result of injury, 70% idiopathic - **Therapy:** find course of the bone marrow failure to carry out hematopoietic functions, immunosuppressive therapy, [bone marrow transplantation.] Drug of choice- antilymphocyte globulin or antithymocyte globulin - **Clinical Manifestations:** - **Beta Thalassemia:** Progressive-chronic anemia (pallor, weakness, splenomegaly), skeletal changes, small build, growth retardation, [facial deformities]. Small body build, delays in sexual maturing, bone changes - Bone changes -- flat bridge of the nose, enlarged head, bones become more brittle and fragile - *Bone marrow is expanding to compensate* - **Aplastic Anemia:** bone marrow failure resulting in the decreased production of all types of blood cells: red blood cells (RBCs), white blood cells (WBCs), and platelets (pancytopenia). - Anemia: Fatigue, pallor, weakness. - Leukopenia: Increased risk of infection. - Thrombocytopenia: Risk of bleeding and bruising. **Blood-Transfusions:** Recognize signs and symptoms of a hemolytic transfusion reaction. What are the priority nursing interventions in this situation? (class power-point, table 24.3 p 809-810; p 809-811) - **Hemolytic Reaction S/S:** Fever, chills, low back pain, dark urine. -- due to incompatible blood -- sudden severe h/a, chills, shaking, fever, pain at site, n/v, chest tightness, red or black urine, and flank pain. - **Priority Interventions for Rxn:** Stop transfusion, maintain IV with saline, monitor vitals, notify provider. Do not restart until the child is evaluated. - Monitor for shock, send blood samples to the lab. Also, can have febrile reactions, allergic reactions, circulatory overload (from excessive quantity of blood), air emboli, hypothermia. - Identify donor and recipient blood types and groups prior to infusion, transfuse slowly over first 15-20 min, save donor blood to recrossmatch with pt blood. - General transfusion guideline -- take v/s prior to transfusion, 15 min after start of infusion, hourly during infusion, and when infusion complete. Give first 50 ml slowly and stay with the child. - Use within **30 minutes** of getting from blood bank - Infuse a unit of blood within **4 hours** - *ABO INCOMPATIBILITY MOST COMMON CAUSE OF DEATH FROM TRANSFUSIONS* **Hemophilia:** Understand the disease process, the most common type, which factor is involved, complications, treatment measures for a child with bleeding, and how to prevent the crippling effects of bleeding (class power-point, p. 799-802) - **Disease Process:** Deficiency of clotting factors, most commonly [Factor VIII (Hem A)]. - X-linked (affects Males) - **Complications:** Tiny spots of bleeding under the skin ([Petechiae]), bleeding around the joints [(Hemarthrosis)] which causes them to be immobile, and [hematomas] in spinal cord causing paralysis) - GI bleeding -- anemia, can bleed into the peritoneal cavity which can be dangerous due to large space for [blood to pool.] Crippling effects of bleeding -- from repeated hemarthrosis (Major cause of disability), incomplete absorption of blood in the joints, limited motion, bone changes leading to contractures. - **Treatment:** - Replacement of missing clotting factor, desmopressin for mild cases, avoid Ibuprofen, physical therapy. - Joints affected, warmth/redness/swelling/pain with movement - **R**est, **I**ce, **C**ompress, **E**levation (RICE) - **Hem A -- missing factor VIII** so DDAVP for mild form or Factor VIII from pooled plasma - **Hem B -- Factor IX** -- concentrated from pooled blood - **Prevention:** [Safe environment] to avoid injuries, use of protective gear. Prompt [trx of hemorrhage and prophylactic therapy] are key to good care and prevention of morbidity. - Education -- use of helmets/face mask/kneepads - ROM exercises after acute phase to help prevent crippling effects - Teach to avoid obesity putting pressure on joints, teach limitations and prevention **Von Willebrand Disease:** Recognize characteristics of this disorder, and teaching education to give. (class power-point, p. 799-802) - **Characteristics:** Prolonged bleeding due to [deficient or defective von Willebrand factor]. - Von Willebrand factor -- glue that helps platelets stick to the walls of blood vessels s[o that the blood clots and stops bleeding especially at wound sites.] - **Parent Education:** Avoid aspirin/NSAIDs, let anesthesia know prior to surgery, teach signs of excessive bleeding, use desmopressin. Can have bleeding bruising after little trauma, nosebleeds, flossing teeth, menstrual periods. - Trx - **DDAVP** -- a synthetic hormone that stimulates release on vw factor into the blood vessels. **Immune Thrombocytopenia:** Affected labs, s/s, treatment, and reason/considerations for splenectomy also with regards to immunizations prior to splenectomy (class power-point, p. 802-804). - **Definition:** An autoimmune disorder that occurs when the immune system mistakenly attacks platelets, which are essential for blood clotting. - Most common thrombocytopenia in children -- usually in those under 10 years old. - Allergic to own platelets -- autoimmune. - **Labs:** Low [platelet] count (\~[100,000], as WNL is 150k-450k) causing prolonged bleeding times. - **S/S:** [Bruising, petechiae, prolonged bleeding.] - Most bruising over bony prominences, bloody gums, bloody nose, internal hemorrhage, hematomas. - **Treatment:** [IVIG, corticosteroids], splenectomy if severe. - [Splenectomy] -- reduce risk of hemorrhage but increased risk of lifelong postsplenectomy infection -- wait until at least 5 years old if possible after vaccines, also will need prophylactic PCN. - Avoid high impact -- football, bike riding, in-line skating, climbing, running. - Activity restrictions can be hard with little ones. - **Immunization Considerations:** [Vaccines required before splenectomy.] - Why? The risk of infection and sepsis is high in the first three months after a splenectomy, so it\'s important to get vaccinated [to prevent severe infections.] **Disseminated Intravascular Coagulation (DIC):** Know the phases of DIC, when to suspect it and what to watch for, and the management (class power-point, p 804). - Characterized by [bleeding] and [clotting] occuring [AT THE SAME TIME] - **Phases:** Clotting followed by bleeding. - **S/S:** petechiae, purpura (red or purple spots on skin), bleeding from lab draws, bleeding from umbilicus/trachea/GI, hypotension, organ dysfunction from infarction and ischemia due to abnormal blood clotting throughout the blood vessels. - **Suspected in:** Severe infection, trauma. - **Management:** Treat the underlying cause, [replace clotting factors] and platelets, supportive care, IV Heparin to stop thrombin forming but limit the use. Clotting factors if infusion blood transfusion, recognize signs and symptoms early *Ex) WHICH DISORDER IS CHARACTERIZED BY THE DEPLETION OF CLOTTING FACTORS AND PLATELETS THROUGHOUT THE FORMATION OF THOUSANDS OF MICROCLOTS IN THE BODY? **DIC*** **Epistaxis (internal nose bleed):** Management and emergency treatment involved (class power-point, p 804-805). - **Management:** Keep the child calm, have the child sit up and lean forward to avoid aspirating blood, tilt head forward, pinch nose, apply cold compress. Apply pressure to the soft lower part of the nose with the thumb and forefinger. - **Emergency Treatment:** Seek care if bleeding persists beyond 10-15 minutes. **Childhood Cancers (Chapter 25)** **Leukemia (cancer of the blood):** Recognize signs/symptoms of leukemia and how common it is in children. Recognize what lab values would look like in a child who has leukemia. (class power-point, p. 830-833) - **S/S:** [Anemia, bleeding, infection,] fatigue, fever, pallor, bruising, bone pain. - [Anemia] - decreased erythrocytes - [Infection] - elevated WBCs - [Bleeding] - decreased platelets - *Normal cells are replaced causing anemia, neutropenia, and thrombocytopenia.* - **SEs vs Toxicity**- - *Teach parents that warning signs are usually from the drugs and not necessarily from returning leukemic cells* - Can be dx with a minor infection such as a cold that doesn't go away or can mimic RA or mono -- might see as weight loss, petechiae, bruising, bone and joint pain -- may find when a kid comes in with an injury. - May see enlarged liver or spleen, fever, swollen lymph nodes, bleeding, bone pain. Might mimic mono or could be incidental finding after an injury. Can have low neutrophils which are important for fighting infection. - **Lab Findings:** - Anemia, decreased erythrocytes, showing infections with high WBC, decreased RBC, and decreased platelets. - Acute Lymphoblastic Leukemia: more in boys and in Hispanics. Can be due to prenatal exposure to x-ray, prior chemo tx, or genetic conditions such as Downs. **Bone marrow aspiration of ALL shows [infiltrate of blast cells]** -- then LP done to check for CNS involvement - **look at peripheral blood smear looking for cancer cells on slide**. Prognosis has increased to long term disease free survival rate for kids with ALL close to 90% in major ped cancer tx centers. Medication adherence with steroids and antineoplastics (cancer treatment drugs) is critical - if less than 95% adherence then risk of relapse increases. - Nursing care directed at regimen of therapy and secondary complications -- myelosuppression, drug toxicity, leukemic infiltration, and protection against infection. **Lymphoma:** Recognize signs/symptoms of lymphoma. Recognize the difference between Hodgkin vs. Non-Hodgkin Lymphoma. (class power-point, p. 833-836) - *This kind of cancer usually causes enlarged lymph nodes or solid masses. Leukemia, on the other hand, is seen in the bloodstream and flows/pumps through the blood.* - Involves the tissue in lymph nodes and tonsils and hemtopoetic systems with formation of blood cells. - 95% survival rate - Epstein Barr virus (leads to mono) may play a role - **S/S:** Enlarged lymph nodes "painless rubbery" upper part of the body, weight loss, night sweats, pain, couch, chills. - Biopsy of nodes looking for Reed-Sternberg cells. - **Hodgkin:** Reed-Sternberg cells (sometimes called Epstein Barr), **localized** (most common with **older kids and teens**) - **Non-Hodgkin:** Aggressive and **widespread** (Seen in the **younger age group**). - **Treatment:** Chemo and Radiation - SEs -- n/v, body changes (steroid effects, alopecia), neuropathy, mucosal ulcerations. May damage thyroid gland hypothyroidism causing fatigue - Educate on increased fatigue/lack of energy -- watch for increased at end of day, falling asleep at dinner, difficulty concentrating. Encourage regular bedtimes, rest, frequent naps/rest periods. Also can cause delayed sexual maturation. **Neuroblastoma:** Know where it arises, "silent tumor", manifestations (class power-point, p 841-842). - Cancer that forms in the nerve tissue. MYCN gene is associated with high risk - **Location:** - Arises from adrenal glands or sympathetic nervous system. - [Abdomen most common site] non tendon mass. - Neck, chest, spinal cord, and brain are also sites. - s/s depend on the location, also maybe increased intracranial pressure causing vomiting (brain). Pain, vomiting, respiratory compromise, depression of the kidney. - **Silent Tumor:** Often metastasizes before diagnosis. POOR PRONGOSIS... - **Manifestations:** Abdominal mass, bone pain, fatigue, lump in the chest, bruising around the eyes **Rhabdomyosarcoma & Retinoblastoma:** Know what type of cancer these are, s/s seen with each, and the treatment and emotional support given/home care (class power-point, p. 846-849) - **Rhabdomyosarcoma:** Soft tissue cancer, seen in muscles. - **S/S:** Painless mass, swelling. - **Treatment:** Surgery, chemotherapy, radiation. - **Retinoblastoma:** Eye cancer, may show white reflex. Retina - Mutation could be before birth, conception, or in utero. - **Cat's eye** - Grossly obvious signs parents see **whitish glow in eye**. **Reflex represents visualization of tumor** as light falls on the mass. - Usually seen by shining light toward the kid as they look forward or with photo flash. - [Strabismus] -- crossed eyes looking in different directions. - Blindness late sign with kids bumping into things turning head to see lateral objects. Pain and glaucoma also late sign. - **Treatment:** Removing part of eye (Enucleation), chemotherapy, and radiation. - neurotoxicity- damaged nerve or brain- adverse affect - tumor lysis syndrome- cancer cells get broken off and released into blood stream- effect heart, muscles, and kidneys - infections increases as neutrophil count decreases- can go into septic shock. - Avoid contact sports, Anemia, n/v- hydration and nutrition, mucosal ulcerations- soft toothbrush, soft diet, puffy face, weight loss, fatigue, easy bruising - **unusual symptoms for cancer- prolonged fever with no real reason, enlarged lymph nodes- non painful, petechiae** - **Emotional Support:** prepare parents for loss of vision and prosthetic/implantation options, education on care of socket/wound care, supportive care with altered appearance of child. Prepare family for a wig if preferred before hair loss begins (alopecia). **Bone Tumors:** Recognize the signs/symptoms of osteosarcoma and Ewings sarcoma. Recognize the differences between them. Age groups involved. Phantom limb pain. (class power-point, p. 842-844) - **Osteosarcoma:** Most common primary tumor in children. Affects long bones, common in teenagers during years of growth. Appears near the growth plates. - **S/S:** May see child limping, decreased activity, may have palpable mass. Unexplained bone pain - **Trx:** Chemotherapy, radiation. More likely to have amputation. - [Phantom Limb Pain:] Common after limb amputation in osteosarcoma. - Limb salvage -- resection of primary tumor w prosthetic replacement of involved bone. - **Ewing\'s Sarcoma:** 2nd most common bone tumor malignancy. Affects bones and soft tissue, occurs in children. Found in bone marrow spaces (long/trunk bones, pelvis, femur, tibia, fibula) - With both r/o trauma or infection, focus on size of mass, weight loss, frequent infection. - **S/S:** Bone pain, swelling, fractures. - **Trx:** Chemo, radiation (less likely for amputation) - Both are rare and aggressive bone cancers both affect adolescents and adults. **Wilm's Tumor:** Recognize signs/symptoms of Wilm's Tumor. (class power-point, p. 844-846) - **Rare kidney cancer- most common childhood kidney cancer** - **S/S:** Abdominal swelling w/ mass in abd, pain, [hematuria], hypertension. - Compression of the mass can cause metabolic changes, metastasis can result in hematuria, anemia, pallor, lethargy. - Do not palpate the tumor - can spread cancer to distant sites, keep encapsulated tumor intact can spill and seed cancer cells into the bloodstream. - **Trx:** Immediate surgery followed by chemo and radiation. **Cancer Nursing Care:** Recognize nursing care and teaching related to: alopecia, tumor lysis syndrome, nausea and vomiting, neurotoxicity, superior vena cava syndrome, spinal cord compression, DIC, hyperleukocytosis. Also, effects with infection, hemorrhage, anemia, altered nutrition, mucosal ulcerations, neurologic problems, hemorrhage cystitis, and steroid effects (class power-points and p. 823-828) ### **1. [Alopecia]:** - **Nursing Care**: Alopecia (hair loss) is a common side effect of chemotherapy. Prepare the child and family for hair loss by discussing options like wigs, hats, or scarves. - **Teaching**: Reinforce that hair will usually grow back after treatment ends. Encourage gentle hair care, avoiding harsh shampoos or hair treatments. ### **2. [Tumor Lysis Syndrome (TLS)]:** - **Nursing Care**: TLS is a life-threatening condition caused by the rapid destruction of tumor cells, leading to metabolic imbalances (hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia). Preventive measures include hydration, monitoring electrolytes, and administering medications like allopurinol. - **Teaching**: Educate the family about early signs (e.g., nausea, vomiting, muscle cramps) and the importance of seeking prompt medical care. ### **3. [Nausea and Vomiting]:** - **Nursing Care**: Common during chemotherapy, controlled using antiemetics (ondansetron, granisetron). Small, frequent meals, bland foods, and ensuring good hydration can help alleviate symptoms. - **Teaching**: Instruct parents on administering prescribed antiemetics and keeping the child hydrated. Encourage eating small amounts of tolerated foods. ### **4. [Neurotoxicity]:** - **Nursing Care**: Certain chemotherapy agents (e.g., vincristine) may cause neurotoxic effects such as peripheral neuropathy. Assess for changes in sensation, weakness, and motor function. - **Teaching**: Educate the family on monitoring for symptoms like tingling, weakness, and constipation, which can also result from neurotoxic effects. ### **5. [Superior Vena Cava Syndrome]:** - **Nursing Care**: Caused by obstruction of the superior vena cava, leading to facial swelling, dyspnea, and cyanosis. Immediate interventions may include raising the child's head and administering corticosteroids or radiation to reduce tumor size. - **Teaching**: Inform families to watch for signs of swelling or breathing difficulties and seek urgent medical attention. ### **6. [Spinal Cord Compression]:** - **Nursing Care**: Tumors pressing on the spinal cord can cause back pain, weakness, and paralysis. Management may include corticosteroids, radiation, or surgery. - **Teaching**: Educate the family to observe and report new onset back pain or changes in motor function, as prompt treatment is essential to prevent permanent damage. ### **7. [Disseminated Intravascular Coagulation (DIC)]:** - **Nursing Care**: DIC is a serious bleeding disorder triggered by cancer. Care includes supportive treatments like transfusions and addressing the underlying cause of DIC. - **Teaching**: Teach families the importance of recognizing bleeding signs, such as bruising, petechiae, or prolonged bleeding, and to seek immediate care. ### **8. [Hyperleukocytosis]:** - **Nursing Care**: A dangerously high white blood cell count, hyperleukocytosis can cause blood flow obstructions. Care includes chemotherapy to reduce leukocyte levels, hydration, and preventing complications such as stroke. - **Teaching**: Explain the risks of high white cell counts and instruct families on recognizing early symptoms like shortness of breath, vision changes, or headaches. ### **[Effects Related to Cancer and Treatment:]** ### **Infection:** - **Nursing Care**: Neutropenia increases infection risk. Implement strict infection control practices, including hand hygiene and minimizing exposure to crowds. - **Teaching**: Teach families about infection prevention at home, such as avoiding sick contacts, good hygiene, and early signs of infection (e.g., fever, fatigue). ### **Hemorrhage:** - **Nursing Care**: Thrombocytopenia can lead to bleeding. Monitor for signs like bruising, petechiae, and bleeding gums. Platelet transfusions may be necessary. - **Teaching**: Instruct families on preventing injury and recognizing bleeding signs. Advise against using sharp objects or engaging in high-risk activities. ### **Anemia:** - **Nursing Care**: Fatigue and weakness are common in anemia. Administer red blood cell transfusions as needed. - **Teaching**: Educate the family on signs of anemia (pallor, fatigue) and the need for rest and proper nutrition. ### **Altered Nutrition:** - **Nursing Care**: Cancer treatment can lead to poor appetite, weight loss, and malnutrition. Use supplements and encourage small, high-calorie meals. - **Teaching**: Provide education on nutritional support, focusing on foods the child likes, and how to maintain calorie intake even with poor appetite. ### ### ### **Mucosal Ulcerations:** - **Nursing Care**: Mouth sores (stomatitis) are painful side effects. Administer pain relief (local anesthetics) and ensure good oral hygiene. - **Teaching**: Teach families about soft, bland diets, avoiding acidic or spicy foods, and using oral rinses to maintain comfort. ### **Neurologic Problems:** - **Nursing Care**: Monitor for chemotherapy-induced neurologic changes (e.g., seizures, changes in mental status). - **Teaching**: Inform parents to watch for new symptoms such as headaches, confusion, or balance issues, and report them immediately. ### **Hemorrhagic Cystitis:** - **Nursing Care**: Certain drugs (e.g., cyclophosphamide) can cause bladder irritation. Increase hydration and administer mesna to protect the bladder lining. - **Teaching**: Encourage increased fluid intake and monitor for signs of blood in the urine or pain on urination. ### **Steroid Effects:** - **Nursing Care**: Steroids like prednisone can cause [weight gain], mood changes, and [increased risk of infection]. [Monitor blood glucose] and mood. - **Teaching**: Educate families on the side effects of steroids, such as increased appetite, mood swings, and susceptibility to infection. **Cancer:** Labs, diagnostics, risk factors, S/S of cancer in children, and management of side effects of treatment (class power-points and p. 817-830). ### **[1. Labs & Diagnostics for Pediatric Cancer:]** - **Complete Blood Count (CBC):** Evaluates for anemia, leukopenia, and thrombocytopenia, common in leukemia. - **Bone Marrow Aspiration/Biopsy:** To confirm leukemia and assess the percentage of blast cells. - **Lumbar Puncture (LP):** Checks for cancerous cells in the cerebrospinal fluid, especially in cancers like leukemia or lymphoma. - **Imaging Studies:** - **X-rays, CT scans, MRI, and Ultrasound:** To locate tumors and assess metastasis. - **PET Scan:** Helps detect cancer activity. - **Tumor Markers:** Specific proteins or antigens in the blood (e.g., alpha-fetoprotein for liver cancer, β-hCG for certain germ cell tumors). - **Biopsy of Tumors:** The definitive diagnosis to confirm malignancy. - **Cytogenetic and Molecular Testing:** For identifying specific chromosomal abnormalities related to cancer types (e.g., translocations in leukemia). ### **[2. Risk Factors for Childhood Cancer:]** - **Genetic Predisposition:** - **Familial history** of cancers such as retinoblastoma, neuroblastoma, and Wilms tumor. - **Chromosomal abnormalities** (e.g., Down syndrome increases leukemia risk). - **Environmental Exposures:** - **Radiation exposure** (prenatal or postnatal). - **Carcinogenic substances** (e.g., chemicals, radiation from treatment for other cancers). - **Viral Infections:** - **Epstein-Barr Virus (EBV)** associated with Burkitt's lymphoma. - **Human Immunodeficiency Virus (HIV)** linked to various cancers. ### **[3. Signs and Symptoms (S/S) of Cancer in Children:]** - **General Symptoms:** - **Persistent fever or infections:** Indicates immune suppression or malignancy. - **Unexplained weight loss, fatigue, or pallor.** - **Lethargy, malaise.** - **Specific Symptoms Based on Cancer Type:** - **Leukemia:** Bone pain, petechiae, bruising, recurrent infections, hepatosplenomegaly, and lymphadenopathy. - **Brain Tumors:** Headaches, morning vomiting, balance issues, vision changes, or behavioral changes. - **Lymphomas (Hodgkin and Non-Hodgkin):** Painless enlarged lymph nodes, chest pain, coughing. - **Bone and Soft Tissue Tumors (Osteosarcoma, Ewing Sarcoma):** Bone pain, swelling, fractures without trauma. - **Wilms Tumor (Kidney):** Abdominal swelling, hematuria, hypertension. - **Neuroblastoma:** Abdominal pain, mass, raccoon eyes, irritability. ### **[4. Management of Side Effects of Cancer Treatment:]** - **Chemotherapy Side Effects:** - **Bone Marrow Suppression (Myelosuppression):** Risk for infections, anemia, and bleeding. Managed with: - **Growth factors** (e.g., filgrastim for neutropenia). - **Blood transfusions** for anemia or thrombocytopenia. - **Gastrointestinal Issues:** Nausea, vomiting, and mucositis are managed with: - **Antiemetics** (e.g., ondansetron). - **Good oral hygiene** and **mucosal agents** for mouth sores. - **Alopecia:** Hair loss occurs; provide emotional support. - **Radiation Therapy Side Effects:** - **Skin Reactions:** Erythema or peeling; managed by using mild skin products and avoiding sun exposure. - **Fatigue:** Encourage rest and balanced nutrition. - **Steroid Therapy Side Effects:** - **Increased Appetite, Mood Swings, Weight Gain:** Support dietary adjustments and coping strategies. - **Infection Prevention:** Due to neutropenia, meticulous **infection control** (hand hygiene, avoiding sick contacts) is crucial. - **Pain Management:** **Pharmacologic** (e.g., opioids) and **non-pharmacologic** (e.g., distraction techniques) approaches. - **Nutritional Support:** Provide **high-protein, high-calorie diets** and supplements to maintain nutritional status during treatment. - **Psychosocial Support:** Offer counseling and support groups for emotional and mental health needs. ### **[Nursing Considerations:]** - Regular **monitoring of labs** for early signs of myelosuppression. - Ensuring **hydration** and managing **tumor lysis syndrome**. - Educating the family about the importance of **adherence** to treatment and **infection control measures**. **Genitourinary Disorders (Chapter 26)** **Urinary Tract Infections:** Recognize the findings on urinalysis that indicate UTI. Recognize risk factors for UTI in children and caregiver education to prevent incidence. (class power-point, p. 855-861, Box 26.1 p. 861 TTC \#4) - **Urinalysis Findings:** WBCs, [nitrites], bacteria. - PH - higher easier for bacteria to grow - specific gravity- higher means lots of bacterial and infection will be more concentrated - **Risk Factors:** Poor hygiene, constipation, dehydration. - Whites, females, and uncircumcised boys - incomplete bladder emptying, concentrated urine, and constipation. - UTI in the first year of life is usually associated with anatomical abnormalities - **Prevention:** Hydration, proper hygiene, avoid bubble baths. - Wear cotton underwear - Goal is to prevent renal scarring - Increased fluid intake promotes flushing of the normal bladder and lowers organism concentration. Encourage increased fluid intake -- 8 oz water per year of age until age 8. - Encourage to void when feel urge and not to hold it. - Sexually active females encouraged to [urinate right after sex] to flush out any bacteria. - **S/S:** dysuria, suprapubic pain, hematuria, fever. Can also include vomiting, not gaining weight, frequent urination, dehydration, foul-smelling urine, poor growth, abd or back pain. If develops into pyelonephritis -- high fever, vomiting, and chills. - ***Takeaway I want you to know:** WBC (and then a culture of it) is what officially diagnoses UTI. Further testing can be done with u/s voiding cystourethrogram VCUG voiding cystourethragram, and renal scans to help identify abnormalities or kidney changes from infection.* - **Rx:** - PCN, Sulfa, cephalosporins, and Macrobid. - ***Labs:*** - ***Specific Gravity** -- how concentrated is the urine? (if lots of bacteria & infection will be more concentrated = higher sp. Gravity)* - ***PH** -- higher pH (more alkaline) is easier for bacteria to grow* - ***Glucose** -- spilling into urine, relevant for a diabetic* - ***Bilirubin** -- liver disease* - ***Ketones** -- Diabetes, diet, poor nutritional intake* - ***Protein** -- if kidneys are not functioning correctly, protein will spill into the urine* - ***Nitrites** -- certain bacteria (gram negative) form nitrites in the urine* - ***Leukocyte Esterase** -- WBC in urine, marker for pyuria* - ***Squamous Epithelial** = usually improperly collected specimen* **Vesicoureteral Reflux:** Recognize this condition, and how it contributes to UTIs in children (class power-point, p. 861-863, TTC \#4) - **Contributes to UTIs:** Urine backflow from bladder to ureters, causing recurrent infections. - Increased risk of progressing to [pyelonephritis] - bacterial infection that causes inflammation in the kidneys - **Grade 5** vesicoureteral reflux (VUR) is the [most severe form] of VUR, a condition where urine flows back up into the ureters and kidneys **Hemolytic Uremic Syndrome:** Recognize what this condition is and common pathogens that cause it. Recognize nursing interventions for management. (class power-point, p. 872-873, TTC \#4) - Usually present with [ gastroenteritis] or URI followed by sudden hemolysis and renal failure. - **S/S:** Triad of **anemia, thrombocytopenia, and renal failure** sufficient for diagnosis. - **Pathogens:** E. coli (Shiga Toxin) - Usually associated with bacterial toxins, chemicals or viruses- Rickettsia organisms, adenovirus, E. coli, shigellae. - **Nursing Interventions:** Fluid balance, monitor kidney function, dialysis if needed. **Phimosis/Hydrocele/Hypospadias/Epispadias/Cryptorchidism:** Be able to distinguish between these conditions, how each one is treated, and caregiver education (class power-point, p. 863-867) - **Phimosis:** Narrowing of foreskin; treatment is circumcision. - proper cleaning of the phimotic foreskin. Teach to not force the foreskin to retract as could cause scarring. - **Hydrocele:** Fluid around the testes; resolves on its own. - Risk of infection or tumor or inguinal hernia - **Hypospadias:** External genitourinary defect - Urethral opening on [underside] of penis; surgical repair. - Educate regarding the need to delay circumcision until after surgical repair- foreskin may be needed for reconstruction during surgery. - May need bladder drain for 5-10 days to help promote healing and maintain position -- bladder spasms can be common and cause pain -- quick but intense, child arching back and knees up to the chest. - While healing -- KY jelly to diaper to prevent sticking and to help avoid bleeding. - **Epispadias:** Urethral opening on [upper side]; surgical repair. - **Cryptorchidism:** Undescended testes; surgery required. - risk for malignancy and infertility **Glomerulonephritis:** Recognize what this condition is and nursing interventions related to treatment. (class power-point, p. 871-872) - **Condition:** Inflammation of glomeruli, often following streptococcal infection. - **S/S:** Hematuria and edema (Cardinal sign), proteinuria, oliguria, flank pain. Elevated BUN, Cr - **Nursing Interventions:** Monitor urine output, blood pressure, restrict fluids and sodium, manage hypertension, rest. - cerebral complications from edema and HPT -- seizure precautions **Nephrotic Syndrome:** Recognize symptoms of this condition, and how it differs from glomerulonephritis. Recognize nursing interventions for management. (class power-point, 868-871) - **Definition:** Kidney disorder that occurs when the kidneys are damaged and leak too much protein into the urine - **S/S:** Massive proteinuria, edema (especially periorbital), hypoalbuminemia, hyperlipidemia. - ***Difference from Glomerulonephritis:** Nephrotic syndrome involves massive protein loss and no gross hematuria.* - **Management:** Corticosteroids, diuretics, low-sodium diet, monitoring for infection. - teach parents to monitor [urine protein with urine dipstick] **Renal Failure:** Acute Kidney Injury features/management/complications. Chronic Kidney Disease pathophysiology and nursing care including dialysis and transplantation (class power-point, p. 873-880) - ### **Acute Kidney Injury (AKI)** - **Features:** [Sudden decline] in kidney function, oliguria, electrolyte imbalances. - **Management:** Correct fluid imbalances, monitor for hyperkalemia, support kidney function, possible dialysis. - **Trx:** Treat cause, manage complications, treat poor perfusion, and dehydration. - **Complications:** Hypertension, seizures, cardiac complications. - Watch for electrolyte loss after diuretic therapy. Measure electrolyte, ph, BUN, and creatinine. - Is reversible - ### **Chronic Kidney Disease** - **Pathophysiology:** [Gradual loss] of kidney function, leads to **uremia** (urine in the blood) - **Nursing Care:** Monitor for growth delays, anemia, electrolyte imbalances. Manage symptoms with diet restrictions, medications, and dialysis or transplantation if needed. - Irreversible (needs dialysis or transplant) **Gastrointestinal Disorders (Chapter 22)** **Diarrhea and dehydration:** Recognize the different physical assessment findings/types/degrees in both dehydration and diarrhea and the nursing management of each one. Know how to evaluate dehydration and recognize the manifestations (Table 22.3 & 22.4) Know the infectious causes of acute diarrhea (table 22.5) What age range is at highest risk with these? Know about water intoxication (class power-point, p 680-694). - **Assessment Findings:** Dry mucous membranes, decreased skin turgor, sunken fontanels in infants, decreased urine output. - Other signs -- LOC change, decreased turgor, increased cap refill, HR, sunken eyes and fontanels. - **Types of Dehydration:** - **Mild:** Normal vitals, slight thirst. - **Moderate:** Increased heart rate, dry mucous membranes. - **Severe:** Tachycardia, lethargy, deeply sunken eyes. - **Nursing Management:** Oral rehydration solutions (ORS), IV fluids for severe dehydration (n/v, unable to take PO) - **Infectious Causes of Diarrhea:** Rotavirus, E. coli, Salmonella, Shigella - Most pathogens that cause diarrhea spread by fecal-oral route by contaminated food or water, person to person spread, daycare center, poor hygiene. - **High-Risk Age Range:** [Infants and toddlers] are most susceptible to dehydration- [immature kidney function.] - **Water Intoxication:** Excessive water intake can dilute electrolytes, causing hyponatremia. **Fluid and electrolyte Balances/Constipation/Vomiting** Recognize disturbances of Fluid and Electrolyte Balance (Table 22.2). Also know how constipation and vomiting affect the pediatric population (class power-point, p. 694-698). - **Fluid and Electrolyte Imbalances** - **Hyponatremia:** Headache, nausea, confusion. - **Hyperkalemia:** Muscle weakness, cardiac arrhythmias. - **Constipation:** Can result from poor diet, lack of fluids, or withholding stool. - **Management:** Increase fluids, fiber, stool softeners. - **Vomiting:** May lead to dehydration, metabolic alkalosis. - **Management:** Anti-emetics, hydration, monitoring of electrolytes. - **Celiac Disease:** Know the manifestations, evaluation, and dietary education to give to kids/parents (class power point, p. 715-716) - **Manifestations:** Diarrhea, failure to thrive, abdominal distention, irritability. - abdominal pain, muscle wasting, anorexia - **Evaluation:** Positive serology tests (anti-tissue transglutaminase), small bowel biopsy. - blood test to determine - **Dietary Education:** Gluten-free diet, **avoiding wheat, barley, rye.** Educate on reading labels and cross-contamination. - more at risk for iron deficiency anemia - cereals baked goods and processed foods- gluten - instead provide- rice, corn, and millet - Celiac Crisis- acute episodes of v/d- brought on by infections, fluid and electrolyte depletion, emotional disturbances **Short Bowel Syndrome:** Know what kind of disorder this is, nutritional support, and home care to provide (P. 716-717). Also know malrotation and volvulus and how short bowel syndrome is a complication (class power-points, p 714-715). - **Disorder:** Malabsorptive disorder - [Loss of significant portions of small intestine], **leading to malabsorption.** - [Decreased mucosal surface area] of the small intestine - Leads to decreased absorption of fluid, electrolytes, and nutrients - **Nutritional Support:** Total parenteral nutrition (TPN), enteral feeding. - high fat, low carb diet for bacterial overgrowth - **Home Care:** Long-term nutrition management, monitoring for growth and development, infection prevention. Prep and equipment for feedings. - education and follow up - **Complications:** Often follows malrotation or volvulus surgeries **Hirschsprung\'s Disease:** Recognize what this condition is and the treatment (class power-point, p. 698-699) - Mechanical obstruction from inadequate motility of part of the intestine. - **Condition:** Absence of ganglion cells in the colon, leading to intestinal obstruction. - distended abdomen, vomiting with feedings, lack of passing meconium. Infants and kids present with chronic constipation -- rectum is empty, tight sphincter, leakage of liquid stool and gas. - **Treatment:** Surgical resection of the affected bowel, temporary colostomy may be needed. - follow low-fiber/high cal/high protein diet - Soave pull-through, Swenson procedure, Duhamel procedure. -- stabilize fluid and electrolytes, enemas prior to surgery. - Prognosis is positive after surgery -- live normal, some have constipation or abd distention. **Intussusception:** Know that this is a potentially life-threatening condition and the pathophysiology. Recognize signs/symptoms, evaluation, and treatment of this condition. (class power-point, p. 713-714) - Venous engorgement leads to blood leaking - currant red jelly stools. - **Life-Threatening Condition:** Telescoping of a portion of the intestine into another, can lead to necrosis. - **S/S:** Sudden abdominal pain, \"currant jelly\" stools, vomiting. - Severe colicky pain with vomiting -- major sign of intussusception. Vomiting and lethargy as it worsens. - More common with males - **Evaluation and Treatment:** Air or barium enema for diagnosis and treatment, surgery if unsuccessful. - Radiologist guided gas enema or ultrasound guided hydrostatic enema as safe treatment but may need surgery if not helpful. If early treatment, low risk of serious complications. Good prognosis and low mortality if early dx. - Sudden onset, palpable mass in right upper quadrant, blood in recto exam **Pyloric Stenosis:** Recognize signs/symptoms, know the cause, and treatment of this disorder. (class power-point, p. 712-713) - **S/S:** Vomiting after feedings, projectile vomiting, fussy and hungry after vomiting, palpable olive-shaped mass in the upper abdomen. - If not prompt dx -- Failure to thrive, dehydration, metabolic acidosis, weight loss. Usually caused by an isolated lesion. Vomiting minutes after feeding, projectile 3 to 4 feet and shortly after feedings if obstruction worsens. Infant hungry, poor weight gain, dehydration. - **Cause:** Thickening of the pyloric sphincter, obstructing gastric emptying. - leading to hypertrophy and increase peristalsis of the stomach - **Treatment:** Surgical intervention (pyloromyotomy). - U/S to detect mass, H&P, upper Gi, labs to detect metabolic changes from vomiting. BUN increased as sign of dehydration. - Pyloromyotomy -- standard surgery- high success. - Preop correct dehydration and met alkalosis otherwise surgery right away. - Postop small feedings with clears -- usually resume with full feedings by 48 hours. **Appendicitis:** Recognize signs/symptoms and treatment. Know the signs seen with peritonitis and the care and prognosis with a ruptured appendix (class power-point, p. 702-704) - **S/S:** RLQ pain (McBurney\'s point), fever, vomiting, rebound tenderness. - Periumbilical pain is first symptom, then nausea, RLQ pain, and then vomiting with fever. McBurney point most common point of tenderness felt with gentle percussion. Rebound tenderness -- pain with palpation and release. - **Peritonitis Signs:** Rigid abdomen, high fever, shock symptoms. - sudden relief of pain, or increase in pain, guarding of abdomen, abdominal distention, tachycardia, fast breathing, pallor, chills, irritability. - **Care:** Surgical removal of the appendix, IV antibiotics for ruptured cases. - Perforation can happen within 48 hours of initial pain - **Prognosis:** Good with prompt treatment, but rupture increases risk of complications. **Med Dose Calculations** **[Side Notes]** **· 1mL/Kg/Hour urine output for children** **o Reck I/O 1-2hrs** **· UTIs can progress into pyelonephritis** **o UTIs commonly E. coli, M \> F** **o Primary prevention of sepsis is KEY** **· Enuresis -- bed-wetting** **o Desmopressin Rx for Trx** **· UTI Dx** **o Fever, high nitrites** **· Wilms Tumor in Kidney** **o DO NOT PALPATE** **o Comes up quickly and metastasizes to the lungs** **o Aniridia - a complete or partial absence of the colored part of the eye (the iris).** **o UTI Education for essay question** **· Urination after sex** To prevent a UTI in both men and women, it\'s important to stay well-hydrated by drinking plenty of water, which helps flush out bacteria from the urinary tract. Practicing good hygiene is essential; women should wipe from front to back after using the bathroom, while men should keep the genital area clean. Urinating after sexual activity can help both men and women clear any bacteria that might have entered the urethra. Avoid holding in urine for prolonged periods, as this can increase the risk of infection. Additionally, wearing breathable, cotton underwear and avoiding tight clothing can reduce moisture and bacteria growth in the genital area. **FROM GU AUDIO SLIDES** - Indicators for dehydration- increased cap refill, abnormal skin turgor, abnormal respiratory rate - fluid loss increases over what the body is able to sustain with blood volume the body compensates and the blood pressure starts to fall - water intoxication- large amounts of electrolyte free water have decreased sodium and can cause CNS S/S. Water moves into the brain more than sodium moves out. Irritability, N/V, seizures increased urine output - iv water overloading, tap water enemas, too fast of dialysis, wrong mix of formula, or increased water ingestion when they are swimming