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232 Cards in this Set

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Your patient weighs 13 pounds 3 ounces. What is the volume required for 24 hour fluid maintenance?
600 ml
Your patient weighs 35 pounds 4 ounces. What is the volume required for 24 hour fluid maintenance?
1300 ml
Your patient weighs 66 kg. What is the volume required for 24 hour fluid maintenance?
1960 ml
List 5 (or more) assessments that would be performed to diagnose dehydration in an infant.
Assess:
Skin (color, warmth, turgor)
capillary refill
heart rate
blood pressure
peripheral pulses
fontanels
mucous membranes
presence of tears when crying
weight loss
intake and output
serum electrolyte results
urine specific gravity (older child)
LOC
(p. 733)
Dehydration is classified as mild when weight loss is less than ______%, moderate if the weight loss is between _____% and _____%, and severe if the weight loss is greater than ____%.
mild < 5%
moderate 5% - 10%
severe > 10%
p.730)
What is the first choice for treatment for mild dehydration in children?
Oral rehydration therapy such as Pedialyte (p.732)
What treatment is used for severe dehydration or when vomiting is uncontrollable?
IV therapy (p. 732)
What type of dehydration is most common in children?
Isotonic dehydration
True or False? Potassium should not be added to IV if child is not voiding at least 1mL/kg/hr.
True
Why should caffeinated soda not be given to a dehydrated child?
Caffeine is a diuretic which will worsen the dehydration
True or False? Because the BRATT diet is low in calories, fat, and protein, its use is recommended for children who are dehydrated.
False
True or False: Stomach emptying time decreases as the child gets older.
False
True or False: Peristalsis is greater in an infant than in an older child
True
True or False: Infants are deficient in some digestive enzymes until 4-6 months of age.
True
True or False: Stomach capacity is 10-20 mL at birth and is about 200 mL by one month
True
GER
-GER in infants usually improves by 6-12 months of age
-GER occurs 3 times more frequently in boys than girls
-Inappropriate relaxation of the lower esophageal sphincter allows gastric contents to return into the esophagus
(pg 1118)
True or False? The best position to place an infant with GER is sitting in an infant seat.
False
Sitting position increases reflux.
Prone position is best (only while awake)
(p. 1120)
List 4 ways that GER is treated.
-Small, frequent feedings, (thickened with rice)
-Positioning (prone)
-Medications (Zantac, Prilosec,Tagamet, Reglan)
-Surgery (Nissen fundoplication – fundus wrapped & sutured around esophagus)
(p. 1120)
HPS
(hypertrophic pyloric stenosis)
-Hypertrophy of the muscles of the pyloric sphincter cause the opening from the stomach to the intestines to narrow, prevents emptying of gastric contents into duogenum, therefore causing an obstruction.
-occurs more boys than girls
-Exact cause is not known; environmental factors, allergies, genetic predisposition suspected.
-Spitting/vomiting usually develop 2nd/3rd weeks of life
-projectile vomiting develops
-may have palpable olive-shaped mass
True or False? Vomiting from GER usually contains bile.
False
What is the main concern with HPS?
Dehydration
Diagnosis of HPS can sometimes be made by palpation. Where would you palpate, and what would the obstruction feel like?
Palpate the epigastric area, above and to the right of the umbilicus (right upper quadrant).
The obstruction will feel like an olive-shaped mass.
(p. 1104)
Besides palpation, list two other methods used to diagnose HPS.
Ultrasound (most common)
Upper GI series
(p. 1104)
True or False? Vomit containing bile, and small bowel movements are signs of HPS?
False
Bowel movements will be small, but vomit will not contain bile.
True or False? Surgery is the preferred treatment for HPS.
True
(p. 1106)
Nursing care for children with cleft lip or cleft palate preoperatively focuses on caregiver support, preventing aspiration and infection, and ensuring adequate nutrition. What is ESSR?
ESSR is a method used to ensure adequate nutrition from bottle feeding.
E = Enlarge (opening of nipple)
S = Stimulate (rub nipple on lower lip)
S = Swallow
R = Rest
After cleft lip repair, an infant should be placed on their backs and arm restraints are often used. Why?
After surgery, protection of the operative site is required.
Placing the infant on their back prevents them from rubbing their face against anything.
Arm restraints prevent them from pulling at sutures.
(p. 1094)
True or False? Cleft palate repair is usually not done until the child is 12-18 months old and is able to drink from a cup.
False
Lip Repair 6-12 wks
Palate repair 6-18 months
Varies by surgeon
palate repair done early to protect formation of tooth buds, infant develops more normal speech pattern, decreases adverse effects
Telescoping of one portion of the intestine into another is called _____.
Intussusception
(p. 1107)
Intussusception
-Occurs most frequently in 3mon-6yr old boys and has a sudden onset.
-A sausage-shaped mass may be palpable in the right upper quadrant.
-Intussusception is a medical emergency; If untreated, it can lead to necrosis, perforation, and death.
True or False? Ribbon-like stools are a characteristic symptom of intussusception.
False
"Red jelly currant stools" are a sign of intussusception
(ribbon stools are Hirschsprung's)
(p. 1108)
What is the treatment of choice for Intussusception?
-non-surgical hydrostatic reduction using barium or air enema (barium or air being forced through the bowels causes the telescoped section of the intestine to return to its correct position)
(p. 1109)
Caregivers for a child who has been treated for Intussusception should be taught by the nurse to watch for signs of intestinal obstruction and recurrence.
What are some of the signs they should watch for?
-Increasing abdominal pain
-Abdominal distention
-Blood in stools
-Bile stained vomiting (occurs in later phases)
-Decreased or absent stools
Hirschsprung's Disease
-congenital aganglionic megacolon
-Caused by the absence of parasympathetic nervous system ganglion cells in large intestine, which prevents peristalsis
-no peristalisis = mechanical obstruction
-Associated with Down syndrome
-Dilation (hypertrophy) of the normal section of the bowel occurs proximal to the defect (before the defect, not after it)
What are the primary manifestations of Hirschsprung’s Disease in the newborn?
-Failure to pass meconium within 24-48 hours of birth
-Abdominal distention
-Bile stained vomitus
-Refusal to feed
-Intestinal obstruction
-ribbon stools or pellet-like
-palpable fecal mass
-failure to thrive
(p. 1126)
True or False? A sign of Hirschsprung’s disease in children is red jelly-like stools
False
Stools may be pellet shaped or ribbon-like
(red jelly stools are intussusception)
(p. 1126)
What is the number one cause of death related to Hirschsprung’s Disease?
Enterocolitis (Inflammation of the small intestine and colon that progresses rapidly leading to perforation of the bowel and sepsis)
(p.1126)
True or False? Children are at greater risk for perforation (rupture) of the appendix because the walls of their appendix are thinner than adults
True
What are some of the signs and symptoms of appendicitis?
-Abdominal pain that begins around the umbilicus and moves to the right lower quadrant
-anorexia
-Nausea & Vomiting
-Normal or slightly elevated temperature (<101°)
-WBC may be elevated
(p. 1135)
True or False? Nausea and vomiting that precedes abdominal pain often indicates appendicitis.
False
With appendicitis, pain almost always precedes anorexia, nausea, and vomiting.
If the nausea and vomiting occurs before the pain, the cause is usually gastroenteritis
Celiac disease is a malabsorption syndrome due to intolerance of gluten. Where is gluten found?
Gluten is a protein found in: BROW
barley
rye
oats (in US b/c processed on wheat machinery)
wheat
What is steatorrhea?
Steatorrhea is large amounts of unabsorbed fats being excreted in the stools, and is one of the signs of Celiac Disease.
True or False? Physiological factors that increase the risk for respiratory problems in children include small airways, fewer alveoli, and increased chest compliance.
True
Inward movement of the soft tissues of the chest wall during inspiration is called _________.
Retractions
True or False? Because a child has smaller airways than adults, the child’s metabolic and oxygen needs are much less than the adult.
False
Oxygen consumption is much higher for a child because of increased basal metabolic rate
True or False? Inadequate dental hygiene can make children prone to tonsillitis.
False
True or False? Second hand smoke and pacifier have been linked with otitis media
True
Why are children under 3 years old more vulnerable to otitis media?
Their Eustachian tubes are shorter, wider, and straighter, and more horizontal than those of older children and adults.
The primary complication from otitis media is conductive hearing loss and related speech problems. List two less common complications of otitis media.
Meningitis and Septicemia
_____ is a high pitched wheeze produced by a high obstruction (obstruction of the trachea or larynx) that can be heard during inspiration and/or expiration.
Stridor
(str-high-dor = high obstruction)
__________ are adventitious lung sounds caused by the passage of air through fluid or moisture.
Crackles (also called rales)
(snap, crackle, pop - has to pass through milk/fluid)
__________ are the sounds heard when air passes through narrowed passages and can be heard in children with lower airway obstruction.
Wheezes
(wheeze has a 'z' - low in the alphabit = low in airway)
Acute Epigiottitis
-a life-threatening bacterial infection
-causes inflammation of tissue around epiglottitis
-can lead to complete airway obstruction
-It is sometimes classified as a croup syndrome
-Children often assume a “tripod” position to assist with breathing
-Life Threatening!
-depressing the tongue is contraindicated (may cause complete airway obstruction)
-most common ages 2-7
How is laryngotracheobronchitis (LTB) different from epigottitis?
LTB is a viral infection.
Epiglottitis is a bacterial infection.
LTB will have a hoarse barking cough.
Usually no cough is present with Epiglottitis (may hear stridor)
LTB is not a life-threatening emergeny.
Epigottitis is a life-threatening emergency.
Bronchiolitis is an acute infection of the bronchioles. What is the most common cause of Bronchiolitis?
RSV (Respiratory Syncytial Virus)
_________ _________ is an exocrine gland dysfunction characterized by abnormal levels of sodium and chloride (“salty tasting babies”) and extremely thick mucous secretions that damages many of the body’s systems, and eventually leads to death.
Cystic Fibrosis
True or False? Children with Cystic Fibrosis are at increased risk for pulmonary colonization of bacteria that release toxins and cause inflammation in the airway.
True
True or False? Males with Cystic Fibrosis are almost always sterile.
True
Name the most common diagnostic test used to diagnose CF
Sweat chloride test
What are some of the clinical manifestations of CF?
Chronic respiratory infections (cough, sputum production)
Pneumothorax
Hemoptysis (coughing up blood)
Clubbing of the nails
Insulin deficiency
Steatorrhea
Vitamin deficiencies (fat soluble vitamins K A D E)
________ is the most common pediatric chronic illness, and is characterized by chronic inflammation, bronchoconstriction and bronchial hyperresponsiveness.
Asthma
Expiratory wheezing is a classic manifestation of asthma. What are some other manifestations?
Chronic cough
Dyspnea (shortness of breath)
Wheezing
Recurrent chest tightness
intercostal retractions
Tachypnea & labored breathing
Chest pain
Irritability
Restlessness
Use of accessory muscles
Nasal flaring
head bobbing(young children)
pulsus paradoxus
Tired b/c of effort to breath
Orthopnea (difficulty breathing when lying flat)
-in severe cases Diaphoresis, Cyanosis, Pallor, and Growth and development retardation
What does a peak flow meter do?
-helps identify when obstruction occurs
-measures peak expiratory flow rates (the fastest speed at which air is forced from the lungs during expiration)
-measured in liters per minute
-helpful in determining the extent of a child’s asthma
Transmitted by contaminated poultry & pets, especially turtles & reptiles
Salmonella
(salmonella sounds like salamander, a reptile)
Most common cause of nosocomial & community outbreaks of gastroenteritis in children 6 months to 2 years
Rotavirus
Associated with undercooked hamburger as well as interpersonal transmission
E. Coli
Surgical repair usually considered only when medical therapy fails
Gastroesophageal Reflux
(GER)
Abdominal circumference often measured along with vital signs to monitor abdominal distention
Hirschsprung & Intussusception
Projectile vomiting develops within 4-6 wks after birth
Pyloric Stenosis
Olive-shaped mass palpable in RUQ
Pyloric Stenosis
Symptoms associated with variations in lower esophageal sphincter pressure such as occurs with gastric distention, delayed gastric emptying.
Gastroesophageal Reflux
Also called congenital ananglionic megacolon
Hirschsprung Disease
Physical Factors to incorporate in an assessment of fluid volume deficit for an infant with possible dehydration
weigh child (& calculate loss)
measure I&O
review urine specific gravity
LOC
pulse rate & quality
skin turgor
mucous membranes
resp rate & quality
BP
thirst
fontanel
capillary refill
Side effects of increased sodium (Hypernatremia)
thirst
decreased LOC:
confusion
lethargy
coma
seizures
Side effects of decreased sodium (Hyponatremia)
(normally, more Na outside cell - a decrease causes fluid to shift to inside the cells)
Muscle Weakness
Cerebral Edema (cells swell)(headache)
Seizures
Also:
anorexia
decreased LOC:
lethargy
confusion
coma
Tonsillitis
Definition
Infection or inflammation of palatine tonsils (hypertrophy)
Causes of Tonsillitis
Group A Beta hemolytic strep
-bacterial
-or viral
Signs & Symptoms of Tonsillitis
- Frequent sore throat infections (5x in 1yr)
-problems breathing
-problems swallowing
-Redness
-enlargement of cervical lymph nodes
Treatment of Tonsillitis
Antibiotics, analgesics, antipyretics, rest
Surgical: focus on care r/t fluid
Why are children are at risk for Tonsillitis?
-large amount of lymphoid tissue in pharyngeal cavity
-Tend to have URI
-around other children that are infected
-immature immune sx more seceptible to a mo invasion
-hand mouth activity
Post Op Care for Tonsillitis
. Monitor bleeding of site & frequent swallowing (primary concern b/c of risk for hemorrhage)*Call Dr ASAP
2. FVD r/t ↓ intake b/c of throat pain when swallowing
3. Pain Level
4. Infection
-Position on abdomen or side for drainage of secretions
-once fully awake child can sit up
-suctioning done gently, prn
-Remind child NOT to cough or blow nose
Tonsillitis:
"Don'ts" after surgery
- avoid red/brown liquids/foods they interfere w/assessment of bleeding
-no straws
-no spicy foods
-no citrus beverages
-no ibuprofen
-no vigorous exercise for 1st wk
Tonsillitis:
"Dos" after surgery
-drink cool fluid
-chew gum
-Tylenol elixir
-ice collar
-eat soft foods
What are some causes of Acute Otitis Media
(AOM)
Most common causative organisms are:
-H. flu
-S. pneumonia
RTI’s cause swelling of Eustachian tube mucus membranes
-Enlarged Adenoids obstruct the E. tubes
-Pacifier use raises soft palate & organ-isms enter easier
-Breathing in second hand smoke dries the E. tubes out & increase risk for infection
-Peak incidence is for children 6-12 months old
-Upper respiratory infection often precedes OM
Acute Otitis Media
(AOM)
Definition
-Middle Ear Bacterial Infection or inflammation in middle ear from pathogens transferred from the nasopharynx
-Bulging or ↓ mobility of tympanic membrane
Acute Otitis Media
(AOM)
Signs & Symptoms
-Red tympanic membrane
-ear pain & fever
-anorexia
-enlarged lymph nodes
-hearing loss
-tug on ear, drainage on pillow
-fussy, irritable, tired
-diarrhea & vomiting
Acute Otitis Media
(AOM)
Treatment
Tx with Tylenol, motrin or after 48-72hr try antibiotics.
Acute Otitis Media
(AOM)
At risk groups
-6mo to 1 yr
-daycare kids
-kids with allergies
-bottle propped when in bed
-exposure to cig. smoke (dries tubes out)
Otitis Media w/Effusion
(OME)
Definition
Collection of fluid in the middle ear behind the tympanic membrane
-NOT INFECTED W/BACTERIA
-NO INFLAMMATION
Otitis Media w/Effusion
(OME)
Treatment
-Can be chronic >3mo
-Associated with HEARING LOSS
- >4mo: myringotomy w/ tympanostomy tubes recommended (incision in eardrum)
-careful observation of hearing acuity development assessment
Epiglottitis
Causes
-Staph
-Strep
**HIB**
RAPID ACUTE ILLNESS (PT GOES TO OR & INTABATED)
-Don’t stick anything ↓ throat in a pt with epiglottitis
Epiglottitis
Treatment
EMERGENCY!!! Keep child calm
-First take child to OR, intubate to maintain airway
-then MD can culture subglottic tissue in OR
-*Culture is done after endotracheal tube has been inserted and child is stabilized
-Start antibiotics before cultures back! May have to change type
-ALERT: Avoid throat cultures and inspection with tongue blades: Laryngospasm!!! Can irritate area and swell & cause airway obstruction
-fluids
-supportive care
-equipment on hand for emergency tracheotomy
-maintain adequate staffing (PICU)
-Secure airway
-oxygenate
-prophylactic Rifampin to family members
Croup
-Starts as RTI (present late fall, early winter)
-common for 6mo - 6yr
-lasts 4 days
-barking cough
-acute edema of laryngeal & subglottic area
-epiglottis & trachea swells
Acute Spasmodic Laryngitis
(Spasmodic Croup)
-The Good – Less serious
-3mo–3yr (don’t get after 3yrs of age)
-Viral
-Sudden onset
-Peaks at night, resolves by morning, Midnight or twilight croup
Acute Spasmodic Laryngitis
(Spasmodic Croup)
Major Symptoms
-URI
-No fever
-mild resp. distress
-croupy cough
-stridor
-dyspnea
-restlessness
-symptoms will waken child and disappear during the day
Acute Spasmodic Laryngitis
(Spasmodic Croup)
Management
-Cool fluids
-cool air
-position upright
-Meds: None
*associated with allergies
Acute Laryngotracheo Bronchitis
(LTB)
Major Symptoms
URI progresses to:
-stridor
-barking cough
-hoarseness
-low grade fever
-Dyspnea
-restlessness
-irritability
-labored Resp
Steroids helpful with Croup
-Oral:
Dexamethasone
prednisone (can crush tablets and use in jelly or applesauce)
-Nebulized:
Budesonide (Pulmicort respules)
-IV:
Solumedrol (real serious cases)
Bronchiolitis
(RSV) Resp Syncytial Virus
Description
-Viral or bacterial inflammation of the bronchioles (*virus invades mucous cells of small bronchioles, cells die/clump together & clog airway)
-95% have this by Age 3
-Peak age 2-6mo
-125,000 admits
-4,500 death/yr (babies <6mo)
What causes Bronchiolitis?
RSV is the most common cause Bronchiloitis
-transmitted by direct contact with resp secretions/contamin.surfaces (12hr)
-kids with serious illness at risk, lungs scar don’t heal
-common in winter months Nov-Mar
Bronchiolitis
(RSV) Resp Syncytial Virus
Signs & Symptoms
-URI
-stuffiness
-cough
-fever
-progressing to lower resp tract
-symptoms ↑ to rhinitis
-low grade fever
-wheezing
-labored breathing
Severe cases:
-Rapid, shallow respirations
-nasal flaring
-marked retractions
-crackles &/or rhonchi
-cyanosis and ↓ breath sounds
Bronchiolitis
(RSV) Resp Syncytial Virus
Treatment
For RSV:
-Isolate
–contact precautions
-Oxygen
-Hydration
-Meds
-humidified ox (thins mucous out)
-IV or oral fluids
-Value of steroids
Best MEDS
-Racemic Epi (bronchodilator)
-Bronchidialtor (neb route used)
-Postural drainage & CPT
LIFE THREATHENING RSV
–Ribavirin (only used in ICU)

Test Question
1st use Bronchodialter
2nd use chest PT
*need to open lungs/airways to allow secretions to be able to come up
*Goal is to loosen secretions
Labs: ELIZA, Assay, chest xray
Bronchiolitis
(RSV) Resp Syncytial Virus
Prevention
Monocional antibody SYNAGIS
-used to prevent RSV
- given to HR kids by IM during peak RSV months
-BEST PREVENTON HAND WASHING
Rhonchi
Coarse low pitched sounds
Thick secretions w/respiratory illness
lower airway
Crackles (rales)
High pitched popping sound during inspiration
-Hair rubbing noise (aveoli pop open)
-Thin watery secretions
-A lot of fluid in lungs
-audible in children with bronchiolitis
-lower airway
Wheezes
-High pitched musical sound
-Narrowing of airways
-Bronchoconstriction of soft tissue swelling
-lower airway
Stridor
-high pitch, seal like barking cough & hoarseness
-Narrowed airway around trachea & larynx
-upper airway obstruction
1. croup
2. partial foreign body obstruction
3. Extubated (had an intubation tube for awhile)
Asthma
Cause
Exposure to a trigger causes: Inflammation which causes:
1. airway bronchoconstriction
2. airway soft tissue swelling
3. mucus production
-Airway remodeling: chronic Inflammatory ▲’s w/ smooth Muscle hypertrophy, thickening of membranes
Common Triggers of Asthma
-exercise
-infections
-allergens (mold, dust, pollen furry pets, birds, cockroach droppings)
-fragrances
-food additives
-pollutants(2nd hand smoke, weather changes)
-emotions
-anxiety
Asthma
Medications
Short Acting Beta Agonists Bronchodilators (given 1st)
-Albuterol (oral or neb)
-Xopenex (neb) NO ↑ HR
Anticholingerics: Inhibits bronchoconstriction & ↓ mucus production
-Atrovent
Corticosteroids: diminish airway Inflammation & obstruction, enhance effects of beta agonists
-Prednisone (po)
-Prednisolone (po)
-Methylprednisolone (IV) Acute Asthma:
1st drug given is Short Acting Bronchodilator
Asthma
Treatment
Medications:
-directly to lungs, less SE
Hydration (oral or IV fluids)
Education
Support of parents/children
*GOAL IS ASTHMA CONTROL
*bronchodilators SE
-elevated HR, but will ↓ in 30min
Determine daily maintenance fluid requirements for a child based on weight
-1st 10 kg: maintenance 100 mL of fluid/kg -2nd 10 kg: maintenance 50 mL of fluid/kg -For remaining kgs, maintenance is 10 mL of fluid/kg -Remember this is maintenance only, if infant/child is dehydrated, a bolus of fluid will be need to restore fluid & electrolyte levels, & then maintenance can begin
Risk for fluid volume deficit r/t ...
-Fever
-Failure to drink enough fluid
-NPO status
-Overuse of diuretics or enemas
-NG suctioning
-Vomiting / diarrhea
-Dehydration
-Increased respirations
-Hemorrhage
Clinical Manifestation of MILD Dehydration
- <5% loss of body wt
-pale, cool skin
-decreased skin turgor
-flat anterior fontanel
-slight thirst
-tears present
-normal/dry mucous membranes
-normal/slightly increased pulse
-BP normal
-decreased urine output
Clinical Manifestation of Moderate Dehydration
-5-10% loss of body wt
-dusky grayish skin
-decreased skin turgor
-depressed anterior fontanel
-moderate thirst
-decreased tears
-dry & sticky mucous membranes
-increased weak pulse
-decreased BP (NOT a reliable indicator)
-oliguria (little output)
Clinical Manifestation of Severe Dehydration
- >10% body wt loss
-mottled skin
-markedly decreased skin turgor
- very sunken fontanel
- intense thirst
-no tears
-parched, cracked mucous membranes
-rapid thready pulse
-low BP
-axotemia (no urine output)
-lethargic
Why is K+ not administered in IV fluid until pt voids?
-kidneys are responsible for excreting K+. -If the pt has not voided, we don’t know if the kidneys are working properly, & infusion of K+ prior to voiding may cause hyperkalemia, which is a serious problem (more serious than hypokalemia)
Common causes of diarrhea
-viruses (rotavirus, Norwalk, Adenovirus)
-bacteria (shigella, salmonella, E. coli, Colstridium dif., campylobacter)
-parasites (giardia,cryptosporidium)
Rotavirus
a virus that destroys/damages epithelial cells in intestinal lining -usually self limiting -MOST COMMON CAUSE OF GASTERENTERITIS in children < 2 yo -occurs in winter months -transmitted fecal-oral route -wash hands
Shigella
-spread person-person or by ingestion of contaminated food -prevention will require proper food handling techniques
Salmonella
-transmitted via contact w/ infected animals & food products (pet turtles, hamsters, cats, dogs, poultry, eggs, and milk)
-prevention: don’t eat raw foods (eggs)
-do not contaminate raw fruits & veggies w/ poultry, etc.
-always wash hands after contact w/ animal feces
-always wash hands after handling reptiles, as they are particularly prone to carry salmonella
E. Coli
-found in uncooked meat (esp. hamburger) -separate raw meat from ready to eat foods -wash hands counters & utensils w/ hot soapy water after they touch raw meat -drink pasteurized milk, juice, cider -wash fruits & vegetables thoroughly -alfalfa sprouts & seeds may not be decontaminated -drink only treated water (not out of streams, lakes or swimming pool)
What is Oral Rehydration Therapy (ORT)
-the treatment of choice for children w/ mild or moderate dehydration
-The solution should contain glucose, sodium, potassium & bicarbonate
-Pedialyte, Lytren, Infalyte and Resol are commercially available
-Popular liquids such as soft drinks, fruit juices, broth, & athletic drinks, Gatorade, Powerade should NOT be used for rehydration
-Homemade solutions can be made per WHO recipie
ORT for mild dehydration
-give 50 ml/kg ORS in 4 hours -replace each loss from diarrhea w/ an additional 10 ml/kg & reassess q 2 hrs. -resume foods, esp. CHO, avoid fats & simple sugars
ORT for moderate dehydration
-give 100 ml/kg ORS -replace losses over 4 – 6 hrs -replace each loss from diarrhea & vomit w/ an additional 10 ml/kg -reassess hourly, treat in supervised setting
Is ORT appropriate for severe dehydration?
NO
What is ENCOPRESIS?
-Constipation with fecal soiling
-More chronic & serious form of constipation
-Watery colonic contents leak around the hard fecal masses and pass through the rectum
-Condition often confused with diarrhea.
What is CONSTIPATION?
-the difficult passage of stool or infrequent passage of hard stool, associated with straining, abdominal pain, or withholding
Hirschsprung’s Disease Therapeutic Management
-surgical treatment: aganglionic segment is resected or removed & normal bowel is anastomosed to the rectum
-May be done between 6-15 mos. of age or wt of 18-20 lbs. (can be a 1 or 2-step procedure if temporary colostomy is created)
-laparoscopic-assisted pull-through: enter body through anus & pull affected segment of bowel through the opening (no major abdominal surgery, & fewer complications)
Hirschsprung’s Disease Nursing Care
Pre-op:
-assess fluid & electrolyte status
-last BM & clean bowels (enemas)
-NPO
-NG tube
-IV fluids & electrolytes to prevent dehydration
-oral & IV antibiotics
-wt
-vital signs
-lab work
Post-op:
-maintain patency of NG tube
-monitor BS & for distention
-colostomy care
Intussusception Pathophysiology
-An obstructive disorder that occurs when one segment of bowel telescopes into the lumen of an adjacent segment of intestine
-The walls of the bowel press against each other & compromise blood & lymph flow, leading to inflammation, edema, & bleeding
-causes blood & mucus in stool ( “currant jelly”)
-Complete bowel obstruction develops, causing abdominal distention & vomiting
-May lead to necrosis & perforation, even death if untreated
-Occurs most often at ileocecal valve.
Intussusception Diagnostic evaluation
-sudden onset of acute abdominal pain, colic
-Ultrasound: reliable & least invasive
-Barium or air contrast enema
-Abdominal X-ray will identify free air in abdomen. (Ruptured bowel)
-Surgery required if perforated, have peritonitis, or hydrostatic reduction not successful
Intussusception Treatment
-hydrostatic reduction with barium, water-soluble contrast, or air enema (less risk of perforation) -Surgery if evidence of perforation, peritonitis, or if hydrostatic reduction is not successful.
Intussusception Nursing Management
Pre-op:
-NPO
-NG tube
-IV fluids
-monitor v/s for changes
-assess abdominal pain
-examine & record all stools
Post-op:
-observe passage of stool & barium
-monitor for recurrence of intussusception
Gastroesophageal Reflux Pathophysiology
-reflux of stomach contents into the esophagus due to inappropriate relaxation of the lower esophageal sphincter
-most common GI disorder in infants, esp. premies & those with neuro issues.
Gastroesophageal Reflux Signs & symptoms
-vomiting
-regurgitation of undigested formula & mucus
-irritability & crying (from reflux = pain)
-difficulty feeding, food avoidance & malnutrition
-occult blood loss (esophagitis causes bleeding whic will be brown in stool from being digested)
-respiratory distress (aspiration)
Gastroesophageal Reflux Diagnostic evaluation
-Clinical history & physical exam
-Upper GI to detect anatomical abnormalities
-Endoscopy to visualize esophagus
-18-24 hr esophageal pH probe study(only used with challenging cases due to high cost)
Gastroesophageal Reflux Treatment
-Dietary modifications: small, frequent, thickened feedings (rice in formula)
-positioning therapy (flat prone or elevated prone)
-Medications:
Prokinetic Agents:
(Propulsid, raglan)
H2 Receptor Antagonists
(Zantac, Tagamet)
Proton-pump Inhibitors
(Prilosec)
-Surgery: Nissen Fundoplication- tightening of the LES
Gastroesophageal Reflux Nursing Management
-in-depth assessment of feeding pattern, positioning with feeding, & burping frequency
-obtain height, weight, & head circumference (plot on growth chart to assess growth problems)
-assess baseline respiratory status (Breath sounds, RR, effort), due to increased risk for aspiration
-educate caregiver (dietary modification, positioning, med. admin., & developmental needs of infant (and on surgery if performed)
Pyloric Stenosis Signs & symptoms
-spitting/vomiting @ 2-3 wks of age & later becomes projectile
-acts hungry & eats again immediately after vomiting
-poor wt. gain, or wt. loss
-dehydrated
-irritable & lethargic
-may lead to metabolic alkalosis
Pyloric Stenosis Diagnostic evaluation
-History & physical palpation of olive-shaped mass in epigastrum, above & to the right of umbilicus
-upper GI
-Abdominal ultrasound (highly accurate)
Pyloric Stenosis Treatment
-surgery: pyloromyotomy (Fredet-Ramstedt procedure)
-has high success rate & is considered curative
Pyloric Stenosis Nursing Management
Pre-op:
-NPO
-assess hydration status (fontanels, tears, m/m, turgor, wt. compared to birth wt.)
-strict I & O
-bowel sounds
-observe for pain & discomfort
-NG tube
Post-op:
-maintain fluid balance
-admin analgesics
-monitor incision site for infection
-admin IV fluids until full feedings are tolerated
-strict I & O
-pain assessment
Assessment of appendicitis
-pain (location, onset and intensity)
-changes in behavior (refusing to play & decreased appetite)
-vomiting
-relief from pain if perforated (followed by increased intensity, abdominal distention, guarding, decreased or absent bowel sounds, elevated temp and shock-like symptoms)
Preop assessment of appendicitis
-NPO
-IV to replenish fluids (electrolyte balance)
-pain meds
Postop care of appendicitis
-administer antibiotics x 24 hrs
-promote comfort (meds, diversion)
-maintain intake (IV, then DAT)
-Prevent atelectasis (TCDB, walk/play)
-prevent infection or recognize early
Perforated appendicitis
-drains from incision site or site open to heal by secondary intention
-IV antibiotics x 7-10 days
-NPO
-NG tube suction
-IV fluids
-pain meds
Associated problems which may occur even with good anatomic closure of cleft-lip & cleft palate
-feeding problems
-speech development problems
-dental problems
-ear & hearing loss problems
-developmental problems
Preop care & associated problems for the child with cleft-lip & cleft palate
-provide support for caregiver
-preventing aspiration & infection
-ensuring adequate nutrition
-Recognize that shock, anger, guilt, frustration and depression normal for caregiver
-demonstrate acceptance of the baby & encourage holding/touch
-show before/after photos of successful surgeries
-teach feeding problems such as poor suction, prolonged feeding time, nasal regurgitation & inadequate weight gain
Postop care & associated problems for the child with cleft-lip & cleft palate
-Major emphasis is protection of the operative area
-Metal strip (Logan Bow) applied to upper lip & taped to cheeks to prevent tension on suture line
-Infant on back or side with arm or elbow restraints to prevent touching or pulling site
-Administer adequate pain medication
-Team approach to follow up care (plastic surgeon, speech therapist, etc.)
Signs & Symptoms of Celiac Disease
-irritability
-listlessness
-weight loss
-abdominal bloating
-pain
-diarrhea
-unexplained anemia
-failure to thrive
-muscle wasting
-delayed puberty or menses
-in adulthood is associated with thyroid disease, diabetes & osteoporosis.
What are the developmental variations that increase the pediatric populations’ risk for acquiring a respiratory systems dysfunction?
-Small airways
-fewer alveoli
-increased chest compliance
-Higher metabolic demands that require more oxygen
Pediatric Differences in Airway
-Small airway: trachea & lower airway 1/3 to 1/2 of the adult’s airway
-Small change significantly increase airway resistance
-fewer alveoli for gas exchange
-greater compliance/flexibility of chest wall in infants (distress may cause retractions)
-increased basal metabolic rate (increases O2 needs)
The infants alveoli
-an infant has a more limited alveolar surface for gas exchange, in relation to height & weight. -By 3-8 yrs, they will have almost the same of the adult.
Higher metabolic demands of the infant
-require more oxygen with limited oxygen stores
-leads the infants or younger children to get hypoxic quickly and develop respiratory distress.
Prevention measures for the child with otitis media
-Minimize exposure to second-hand smoke (irritates the Eustachian tube)
-Feeding practices: NO horizontal positioning during bottle feedings b/c this allows formula to trickle into Eustachian tube
-Immunizations
What are the complications of otitis media?
-conductive hearing loss -related speech problems (less common complications include abscess formation in the tissues adjacent to the middle ear, meningitis, and septicemia)
Abnormal breath sounds in children
-Stridor -Wheezing -Crackles -rhonchi
Wheezing
-air through narrowed airway -high pitched musical sound -audible lower airway obstruction.
Classic manifestation of acute epiglottitis
-abrupt onset
-respiratory distress (nasal flaring, retractions, inspiratory stridor before complete occlusion)
-fever > 102.2
-dysphagia (difficulty swallowing)
-dysphonia (muffled, hoarse or absent voice sounds
-drooling (from edema/pain)
-agitation (irritable, restless)
-classic tripod position (child sits upright & leans forward, chin is thrust out & mouth is open to attain the best airway possible)
-no spontaneous cough
Laryngotracheobronchitis (LTB)
-a type of croup caused by a slowly progressive virus in which swelling occurs along the trachea & bronchi
LTB diagnosis
-child’s history
-physical examination
-chest film
-WBC with differential count
Laryngotracheo-bronchitis (LTB)
Treatment
-corticosteroids (anti-inflammatory reduces airway edema)
-cool fluids (thin secretions & facilitate removal)
-rest & comforting measures (reduces metabolic demands)
*best tx is steroid & Heilox & 02
***Pts DO NOT benifit from mist/humidifiers***
Pathophysiology of CF
-genetic disease
-autosomal recessive gene mutation on Chromosome #7 (both parent must carry the CF gene in order for the child to be born with CF)
-Both parents carriers but don’t have = chance of child with CF is 25%
-50% chance will only be a carrier & 25% chance will not have CF or carry gene
-1 in 2500 born with CF per year
-exocrine gland dysfunction
-abnormal levels of Na & Cl
-Cl moves out of cells & is lost through skin
-Na is retained & reabsorbed
-result of abnormal Na/Cl causes increase in mucus (amount and thickness) & leads to an increased risk of lung infections & obstruction in other body systems
The GI tract/genitourinary system & CF
-sticky mucus blocks the pancreatic ducts (no enzymes get out)
-lack of enzymes needed to aid digestion results in auto digestion of the pancreas
-Pancreatitis & DM are common complications
-pts may experience meconium ileus at birth (typically the 1st sign of CF
-newborn does not have meconium BM because thick & lodged, surgery to remove the blockage is indicated)
-other problems that may occur are rectal prolapse, gastroesophageal reflux, hepatic diseases, & infertility (more so in boys then girls).
Chronic respiratory infections & CF
-cough
-sputum production
-hyperinflation of the alveoli
-bronchiectaisi
-eventually pulmonary insufficiency & death
CF complications resulting from airway obstruction & tissue damage
-Pneumothrorax
-hemoptysis (coughing up blood)
-atelectasis (collapse of a portion of lung, usually because of surfactant depletion)
CF complication resulting from chronic hypoxia
Clubbing
How is CF diagnosed?
-Medical history
-Physical examination
-Lab tests (look for effects of the disease in specific body organs)
-Chest films (show bronchiectasis: a lung condition characterized by irreversible dilation & destruction of the bronchial walls) & (pneumothorax: a collection of air or gas in the pleural cavity)
-Sweat tests (#1 way to diagnosis: positive if 60mEq/L or greater: test measures amt salt in their sweat)
-DNA analysis
CF Interventions / Collaborative interventions
1. Chest PT
2. Nebulizer meds are used to thin secretions & to possibly give antibiotics. Dnase is used to decrease mucus viscosity aka pulmozyme, TOBI
3. Breathing exercises (IS, TCDB)
4.Antibiotics- 1st try oral then go to PICC/ Central line for long term IV abx.
CF Teaching to families
1. give enzyme before each meal & snacks
2.Vitamin supplements- Fat soluble vitamins – ADEK and typically iron as CF patients are usually iron deficient
3. diet high in calories, fat & protein. Recommended that the diet exceed 150% of the RDA
4. increase fluids & salt intake especially if hot, sweating, or have a fever. (Most babies have extra salt added in their bottles!)
5. assess for intestinal obstruction & rectal prolapse
Asthma
a chronic respiratory illness /chronic inflammatory disorder of the airway
Asthma airway obstruction & air trapping leads to what?
-ventilation/perfusion alterations
-an increased work of breathing
-hypercapnia
-hypoxemia
-(If left untreated, respiratory failure & death)
What is RAD?
RAD = (reactive airway disease) = small babies are diagnosed this for insurance purposes, instead of asthma.
What do asthma triggers/allergens stimulate?
-an increase in circulating IgE, mast cells, and macrophages
-cause the release of other substances such as histamine, basophils, eosinophils, neutrophils, platelets, T lymphocytes, and prostaglandins
-result is bronchoconstriction, mucosal edema, & increased mucus production.
Asthma Treatment/Prevention
-Avoidance of triggers (primary means of preventing symptoms of asthma)
-Regular peak flow monitoring
-Medications
-Family education (best defense!!) teach about affects of meds & importance of avoiding triggers
-On-going follow-up
-Rapid access to medical care
-Adequate sleep & nutrition
-Relaxation & warm-up exercises
ED/hospital care of Asthma
-Hydrate
-Oxygenate/ventilate
-Treat infection
Asthma: Acute Relief Meds
- Short-acting beta agonists-bronchodilators:
1. Albuterol (proventil, ventolin)
▪Oral & nebulized
▪Side effects: ↑ heart rate, jittery, shakiness
2. Levalbuterol (xopenex)
▪Nebulized
▪less S.E of ↑ heart rate
Asthma: Adjuncts to Quick Relief/Rescue Meds
1. Anticholinergics: Improve smooth muscle tone & aid effectiveness of beta-agonists. Inhibits bronchoconstriction & decreases mucus production
e.g. pratropium (Atrovent) (inhaled)
2. Corticosteroids: Diminish airway inflammation and obstruction, enhance effects of beta-agonists.
e.g. Methylprednisolone (IV), Prednisolone (po), Prednisone (po).
Asthma: Long Term Control Meds
1. Long-term Controllers-preventive e.g. ▪ Long-acting bronchodilators ▪ Mast Cell inhibitors ▪ Inhaled corticosteroids ▪ Leukotriene modifiers ▪ Allergy shots 2. Long-Acting Bronchodilators e.g. ▪ Formoterol (Foradil) ▪ Salmeterol (Serevent) ▪ Albuterol-sustained (Vospire) ▪ Methylxanthines (theophylline) Relaxation of smooth muscle in airway. Used for nocturnal symptoms and prevention of exercise-induced bronchospasm.
Purpose of the peak flowmeter
-Measures the fastest speed (in liters/min) at which the air is forced from the lungs during expiration, peak expiratory flow rates (PEFR)
-PEFR is lowered during acute asthmatic episodes because of impaired expiration & air trapping that occurs as a result of airway obstruction
-There are zones on the peak flow meter to determine the level of asthma
Peak Flowmeter Zones/Level of asthma
-Green: 80-90% of personal best (at top of gauge) -Yellow: 50-79% of personal best (middle range of gauge) -Red: <50% of personal best (bottom of gauge)
Why is it important to measure the PEFR when the pt is well?
to get a baseline for determining effectiveness of expiration
Why should PEFR be measured before & after bronchodilator use?
to determine effectiveness of medication
Possible ND for a child with RSV (bronchiolitis)
-Impaired Gas Exchange (excess/deficit in oxygenation and/or co2 elimination at the alveolar capillary membrane (something has changed the function of your alveoli, like you've been working too long in a coal mine or something)
-Ineffective Breathing Pattern (inspiration and/or expiration that does not provide adequate ventilation (like hyperventilating and for some reason no one has a paper bag in their pocket)
-Ineffective Airway Clearance (r/t air trapping and increased mucous production) (inability to clear secretions or obstructions from respiratory tract to maintain a clear airway.(like an asthmatic))
Interventions for a child with RSV (bronchiolitis)
-Humidified O2 (to improve sats and loosen secretions)
-Bronchodilators (help open the airways)
-Corticosteroids
-Ribavirin (may decrease severity of illness, only given to at-risk populations)
-More frequent monitoring of VS
-Assess breath sounds for clearing
-CPT (to loosen secretions) and suctioning (to help remove them)
-Raise HOB 30 degrees (improved chest expansion)
-Continuous pulse ox
-Cardio-respiratory monitor
-Contact isolation
-Possible antibiotics if develop secondary bacterial pneumonia
-IVFs
-Mechanical ventilation for those who have progressed to respiratory failure
-Caregiver education
Clinical manifestations of constipation
-hard, small stools passed at regular intervals or large masses of stool at intervals of days to weeks
-abdominal pain and/or distention develop
-child may be irritable
-loss of appetite
-often a palpable mass is felt on examination
Diagnositic tests of Hirschsprung Disease
History
Rectal Exam
Barium enema or UGI (upper GI series)
Rectal biopsy (definitive diagnosis)
What is the difference in GER & GERD?
-GER, is occasional relux expected in newborns because of immature GI system
-GERD is a reoccuring problem that a pt does not grow out of.
Increased Potassium
causes cardiac problems
may be sign of kidney disorder, dehydration with decreased urine output, or lysis of RBC from injury (released K)
Decreased Potassium
causes cardiac problems
What are the GI differences in Infants?
-decreased stomach capacity (smaller, more frequent feedings)
-increased peristalsis (reflux common)
-LES tone is decreased (reflux common)
-increased stomach emptying rate
-increased metabolic rate
GI differences that relate to Fluid & electrolyte balance.
-increased ECF until 2yo (F&E lost quickly, adjust slowly)
-Increased insensible fluid loss per body surface area
-increased BMR
-Ineffecient kidneys (can't concentrate/dilute urine or conserve/excrete Na
How does urine change in the dehydrated pt?
-color may darken
-specific gravity increases
-smell becomes stronger
-amount decreases
What are some changes in serum lab values in the dehydrated pt?
-Bun increases to 20-30's
-Hg remains the same while Hct increases
-Creatinine remains the same
Gastroenteritis: Definition
-Inflammation of lining of stomach & intestines with rapid onset of diarrhea
-may be associated with fever, vomiting, abdominal pain, wt loss, electrolyte imbalance
-usually self limiting
How is Gastroenteritis transmitted?
-fecal/oral
-ingestion of contaminated foods
-contact with contaminated animals
-injestion of parasite cysts
What causes Gastroenteritis?
Viruses, bacteria, parasites
Common causitive agents include Rotavirus, Salmonella & E. Coli
How do you diagnose Gastroenteritis?
-History (travel, food prep)
-Stool culture if > 24hr
-Blood tests (for electrolytes)
-physical exam (wt loss, dehydrated, toxic appearance)
What is the management of diarrhea with dehydration?
-assess fluid & electrolyte imbalance
-rehydrate
-maintain fluid therapy
-reintroduce adequate diet
What is the best monitor of improvement with Dehydration?
Weight
What foods should the pt avoid when they have Gastroenteritis? Why?
-Fruit juices (high in sugar, apple juice draws water to bowels)
-Caffeineated soda (high in sugar, increases peristalsis, diuretic)
-Beef/chicken broth (sodium draws out water)
-Bratt diet (not enough nutrients)
-high fat foods (hard to digest)
***If we don't feed the gut, it becomes unable to digest other foods***
Does Diarrhea result in metabolic acidosis or alkalosis?
Acidosis
(you are losing base when you excrete)
Does Vomiting result in metabolic acidosis or alkalosis?
Alkalosis
(you lose acidic gastric contents when you vomit)
GI malabsorption syndrome
Celiac Disease
How do you diagnose Celiac Disease?
-biopsy of small bowel (atrophic villi found - is a definitive dx)
-IgA testing
-gluten free diet resolves s/s
What are some common causes of constipation & encopresis?
-dietary (lack of fiber)
-structural disorders
-metabolic/endocrine disorders
-nerogenic disorders
-medications
-suppressing the urge to defecate
What are some treatments for constipation and encopresis?
-cleanse the bowel (enemas, stool softeners, digital removal)
-modify diet
-establish a regular defecation pattern
An x-ray shows air in the abdomen. What might this mean?
Perferation!
A GI motility disorder
Hirschsprung Disease
Obstructive GI disorder
Pyloric Stenosis
Intussusception
The ileocecal valve is the common site for what disorder?
Intussusception
A GI inflammatory disorder
Appendicitis
What is Appendicitis?
-an inflammation of the vermiform appendix
-most common cause of surgery in children
-kids often rupture within 48 hr of first s/s
Pathophysiology of Appendicitis
An obstruction causes edema & compression of vessels. This causes inflammation, ischemia, ulceration & infection. Untreated, progresses to perforation & peritonitis
How is Appendicitis diagnosed?
-History/presentation
-Labs
-Ultrasound
Where are aspirated contents usually found?
On the Right!
Areas to include in a respiratory assessment
-Chest symmetry, movement, retractions
-Skin color
-Type & effort of breathing
-auscultate side to side, front to back
Retraction Sites
Supraclavicular (above clavicles)
Suprasternal (above sternum at base of neck)
Intercostal (between ribs)
Substernal (below sternum/xiphoid process)
Subcostal (look at a picture)
Rhonchi
-course, low pitch sound associated with thick secretions
-associated with bronchiolitis
-lower airway
Breath sounds of the lower airway
Rhonchi, Wheezes, Crackles
Breath sounds of the upper airway
Stridor
True or false? Infants are obligate nose breathers?
True
They prefer to breathe through their nose.
Respiratory rates for ages 1-2 years old
20-40 resps per minute
Signs & symptoms of respiratory distress
-nasal flaring
-mouth open wide
-head bobbing
-use of accessory muscles
-color (pale/cyanotic skin/mucosa)
-grunting
-tachypnea
-mottled skin
-decreased LOC
What is hypoxia?
decreased O2 to tissues
What is hypoxemia?
decreased O2 in blood
What is hypercapnia?
increased CO2 in blood
When does respiratory failure begin?
When O2 & CO2 reach abnormal levels and hypoxia occurs.
Oxygen therapy
-by nasal cannula
-by mask
-humidified O2 decreased risk of infection & dryness & loosens secretions
-weaning: check q 15min
Upper airway infections include ...
Pharyngitis
Tonsillitis
Otitis Media
Epiglottitis
Croup
Lower airway infections include ...
Bronchiolitis
Pneumonia
Tuberculosis