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97 Cards in this Set
- Front
- Back
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Mortality in Childhood
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infants usually die from congenital malformation, short gestation, LBW (b/c of fertility Tx & multiples)
accidents and homicides are top killers of kids (especially males) <1yo usually die from suffocation >15yo usually die from poisoning |
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Risks for Morbidity
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Homelessness: ↑exposure to disease, ↓safety
Living in poverty: ignoring preventive care, ↓access LBW Chronic illness Foreign-born: ↑exposure to diseases, ↑mental illness Day care exposure: ↑exposure |
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Leading cause of hospitalization
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1-9yo: respiratory disease b/c smaller airways & inability to physically cope w/ mucous
10-14yo: mental illness (brings more awareness to pt), GI disease 15-21: pregnancy & childbirth ⇒ must ask sexual activity injuries have top rankings in all ages |
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Injuries in Pediatrics
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leading cause of hospitalization
males > females prevention is key, necessary in teaching must determine: accident v intentional, medical attention sought immediately, location of injury/does story make sense? |
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DEVELOPMENT: Infant 0-6months
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Erikson: trust v mistrust
Piaget: sensorimotor stage (subtage 1-3) hospitalized infant: ➧physical needs: hunger, comfort, warmth ➧safety: sensorimotor, activity level, hospital equipment needs monitoring ➧communication: voice tone, play, parent present, awareness of overstimulation ➧fears: stranger anxiety at beginning ➧coping: parent, familiar adult (consistent care), rocking, stroking, distraction |
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DEVELOPMENT: Infant 6-12months
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Erikson: trust v mistrust
Piaget: sensorimotor stage (substage 3-5) hospitalized infant: ➧safety: MOBILITY, hand-mouth activity, food sections, curious ➧cognitive status: interactive, means-ends, early problem solving ➧emotional status: wary of strangers, shows joy/anger/frustration ➧coping: parents, activity, distraction |
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Nsg Assessment of Hospitalized Infant
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examine in parent's arms or lap if possible
VS, abd while quiet/sleeping delay examining head and mouth quiet voice, don't elicit startle reflex use distraction if begins to cry |
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Nsg Care of Hospitalized Infant
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note obvious, subtle signs of discomfort/distress
en face, eye contact when providing care comfort after painful procedures support for their caregivers is the best way to provide support respect parent wishes regarding presence during procedures |
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DEVELOPMENT: Todder 18mon-3yo
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Erikson: autonomy v shame/doubt
Piaget: sensorimotor - preoperational stage hospitalized todder: ➧safety: toy, play, equipment, water ➧communication: able to talk about what's happening, literal interpretation of words, rapid ↑vocab receptive ⇒ expressive language ➧fears: seperation anxiety peaks 18mon, active imagination (coincides w/ reality) ➧coping: protest, temper tantrum, regression, transitional object |
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Nsg Assessment of Hospitalized Todder
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introduce self, explain what will do, be selective in language
allow movement if possible ("let me help you hold still") parent available for support VS, abd while quiet head, mouth last incorporate play as appropriate (neuro exam) allow to hold the equipment to ↓fear praise cooperative behavior, allow to cry/scream |
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Nsg Care for Hospitalized Todders
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observe for verbal, nonverbal signs of discomfort, distress
explain response protest to parents provide home routines, independence, mobility as much as possible find out how the toddler likes to be conforted take special care of beloved toys, transitional object provide simple directions, choices (careful wording) |
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DEVELOPMENT: Early Childhood/Preschooler 3-5yo
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Erikson: initiative v guilt
Piaget: preoperational stage (preconceptual ⇒ intuitive stage) hospitalized preschooler: ➧safety: self-care, play ➧communication: preoperational thinking, magical thinking, sense of imminent justice (thinks of illness as punishment & likes to be clear about consequences), asks questions to learn about environment and interaction (turns serious questions around) ➧fears: bodily harm, separation ➧coping: activity, rituals, regression, attack, ask questions, dramatic play |
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Nsg Assessment of Hospitalized Preschooler
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may be willing to sit on bed/exam table w/ parent holding hand/nearby
may be unwilling to completely undress (beginning to see value in security/privacy) VS, abd first, head next maybe, genitals last use simple explanations allow to "help" by holding stethoscope |
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Nsg Care for Hospitalized Preschooler
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encourage involvement in learning to maintain sense of initiative
let child know how is caring for him/her, who to call for help facilitate conversation by knowing about current television shows etc emphasize that Txs are not punishment, explain reasons for Tx explore child's perceptions and understanding of illness & Tx (kids who fear death are usually scared of families being upset or if it will hurt) |
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DEVELOPMENT: Middle Childhood/School Age 5-8yo
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Erikson: initiative v guilt ⇒ industry v inferiority
Piaget: preoperational stage (intuitive stage) hospitalized middle child: ➧safety: PREVENTATIVE (bike, pedestrian, sports) ➧communication: logical thinkers & use verbal exchange to understand events; hesitant to share feelings ➧fears: multiple; loss of control; injury/pain ➧coping: aggression, withdrawal, projection, ritual, humor |
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DEVELOPMENT: Late Childhood/School Age 8-12yo
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Erikson: industry v inferiority
Piaget: concrete operations hospitalized late child: ➧safety: activities/equipment (will play with); sports ➧communication: more advanced cognitively, make use of sensory and procedural info d/t gaps in logic; technologically aware ➧fears: losing status, not having friends, not doing well in school, disappointing parents ➧coping: control, 'bossy' practice, self-critical ⇒ set strict limits over what they control |
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Nsg Assessment of School Age Kid
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simple explanations of how equipment works or reasons for procedures, findings
colorful (younger) or digital (older) equipment may help cooperation respect the child's desire to avoid pain, insult |
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Nsg Care of School Age Kid
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reduce fear of the unknown w/ teaching & explanations (younger need more prep time, older need less)
visual aids, stories are helpful for younger, demonstration for older encourage creative expression of responses to experiences (drawing, journaling) use humor, jokes to enhance coping encourage contact w/ friends, introduce other same age kids on unit encourage schoolwork ASAP |
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DEVELOPMENT: Adolescence (Early, Middle, Late)
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Erikson: identity v role confusion
Piaget: formal operations hospitalized teen: ➧safety: personal, risky behaviors ➧communication: adult vocab; cognitive conceit;abstract thinking; solves verbal & mental probs ➧fears: body image; being different; separation from peers ➧coping: imaginary audience, intellectualization; rationalization, denial of |
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Nsg Assessment of Hospitalized Adolescent
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PRIVACY even with fall precautions
approach w/ respect; adult-like Tx use and explain proper terminology avoid cutesy childlike equipment when possible |
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Nsg Care of Hospitalized Adolescent
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plan uninterrupted time for teaching and for responses
encourage involvement in decision making ⇒ negotiate ⇒ establish rules for hospital environment indifference and bravado may indication poor coping encourage reflective journals, creative means of expression use correct language, explain medical terms encourage discussion rather than lecturing for health teaching place topics in perspective |
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Family Theory of Stress
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A+B+C=X
A: stressor B: resources C: perception of event X: crisis or not (response) some families don't consider certain things as stressors b/c of different coping levels |
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Parent emotions
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can be from minor things
shock & disbelief anger & guilt deprivation & loss anticipatory waiting readjustment or mourning: often w/ families w/ chronic illness ⇒ guilt |
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Parents' needs
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info: be honest about what you don't know
proximity: parents allowed at all times except sometimes emergencies & rounds parental control: give control to what they can control ⇒ use as partner participation in child's care confidence in health care providers & Tx psychological support |
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Siblings' Emotions & Needs
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emotions: angry, jealous; or very loving, caring (back-&-forth, varying)
needs: inclusion; be developmentally appropriate; preparation (can be shocked and need help understanding) |
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9 Elements of Family-Centered Care
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1. Recognize the family is the constant
2. Facilitate family & professional collab 3. Honor diversity of families (most cultural practices ARE ALLOWED) 4. Recognize family strengths 5. Share complete and unbiased info 6. promote family-to-family support & networking 7. incorporate developmental needs 8. implement comprehensive policies & programs 9. design accessible health care systems |
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Responses to Stress/Separation by Child
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protest: is fine b/c kid still has some fight
despair: worrying b/c losing hope (in parent) detachment or denial: very worrying b/c losing connection to family |
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Infant Pain Expression
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nonverbal behaviors or cry to express (<6mon, facial scrunch); restlessness, clinging or whining; frantic activity; inconsolable
↓activity, sleep more, ↓interest in environment, ↓eating check diaper, hunger, etc before assuming pain later sullen & withdrawn if pain needs not met |
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Early Childhood Pain Description & Expression
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Description:
➧relate to pain as physical experience ➧someone held accountable for pain ➧fears loss of/change to body integrity ➧magical disappearance of pain ➧more likely to strike out physically/verbally when hurt (⇒ "help" hold still) Expression: ➧language: boo-boo, owie ➧cry/scream is combo of fear/pain ➧requests band-aids regardless of healing stage |
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Middle and Late Childhood Pain Description and Expression
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Middle Description (concrete operational):
➧can point to location of pain ➧fears bodily harm ➧↑injury-related guilt ➧responds well to activities that control pain ➧has cause/effect understanding Late Description (concrete/transitional): ➧cause/effect understanding for etiology & intervention r/t pain ➧response r/t level of anxiety ➧responses may not be honest in order to save face ➧benefit from procedure rooms instead of own room Expression: ➧able to provide description, intensity of pain ➧requests relief, understands time & coping strategies |
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Adolescent Pain Description & Expression
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Description (formal operational):
➧can problem solve but lacks experience ➧fears losing face ➧hesitant to express feelings ➧privacy necessary in coping ⇒ find underlying reasons ➧seeks info Expression: ➧quiet, sullen, moody, irritable, uncooperative, demanding ⇒ differentiate b/t normal teen behavior from pain experience ➧asks multiple questions to keep nurse nearby w/o admitting this need ⇒ reassure |
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5 Principal Strategies of Pain Management
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anticipate & prevent: b/c it's harder to catch up so Tx proactively
adequately assess use multi-modal approach: can add in CAMs besides meds involve parents and patients use non-noxious routes |
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Pain Management Options
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pharmacologic:
➧oral ➧IV ➧PCA pumps: may be on med baseline & Tx more when kids want ⇒ BAD if parents give b/c give too much ➧EMLA: topical numbing lotion ➧epidural nonpharm: ➧parent involvement ➧cognitive behavioral interventions ➧biophysical interventions bring BOTH options |
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Child/Parent Preparation for Procedures
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parents encouraged to be present but nurses determines if they are being supportive or need support themselves
Child Life Specialist: pre-procedural prep & support during procedures painful procedures should be done in Tx room |
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Physiological Differences in Kids' Respiratory System
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abdominal breathers: abd moves up/down (ok in little kids, not in older)
chest wall more compliant: in resp. dist., can see ctx higher risk of airway obstruction: small airways ↑RR: ➧0-1yo: 30-60 ➧1-3yo: 24-40 ➧3-6yo: 22-34 ➧6-12yo: 18-30 ➧12-18yo: 12-16 ↑O2 consumption: body uses more O2 ⇒ even ↑ in illness right bronchi more vertical: aspirations will usually be here |
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General Nursing Assessment of Respiratory
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RR
symmetry S/S distress: retractions (esp subcostal area w/ pulling under ribs), nasal flaring, head bobbing (infants), grunting (creates + pressure) ⇒ working to breathe color of skin clubbing: result of chronic hypoxia (ex. CF) cough |
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Respiratory Infection Risk Factors
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viruses: usually upper airway, common
age: little kids have passive immunity from mom until daycare size: shorter distance b/t nasopharynx & nose; smaller airways resistance: ↑risk w/ underlying disease seasonal changes: winter & spring; RSV all year |
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Acute Vitral Nasopharyngitis
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causes: rhinovirus, RSV, adeno, influenza,
S/S: ➧low grade fever ➧irritable ➧anorexic/fatigued b/c can't coordinate sucking/eating & breathing ➧nasal discharge & inflammation initially self-limited/supportive care: ➧good fluids (PO on good resp status) ➧cleaning nose ➧Tylenol for temp management ➧no cold meds for congestion b/c usually brings more probs ➧supplemental O2 |
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Pharyngitis Etiology & S/S
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complications: acute rheumatic fever or acute glomerulonephritis if unTx
Viral (mild): ➧sore throat/red pharynx ➧low grade fever ➧general malaise Bacterial (abrupt onset): ➧pharyngitis ➧difficulty swallowing b/c throat raw ➧headache ➧high fever ➧abd pain ➧inflamed tonsils & pharynx ➧tender lymph nodes |
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Tonsillitis S/S
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excudate visible
very bad breath lost sense of taste/smell probs w/ swallowing, breathing ↑risk of Otitis Media (from large tonsils or repeated episodes) |
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Pharyngitis & Tonsillitis Diagnosis
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must culture to determine viral v bacterial
1) rapid strep + ⇒ Dx 2) rapid strep - ⇒ throat culture + ⇒ Dx |
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Pharyngitis & Tonsillitis Tx/Nsg Care
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monitor resp status
minimize S/S: ➧clear nasal passages ➧liquids/soft foods (but not citrus) ➧ cool mist ➧compress (unless already feeling compressed) ➧(salt water) gargles if helpful meds: ➧Tylenol: fever ➧nonalcoholic cough suppressants: post-nasal drip difficult to manage ➧decongestants ➧antibiotics for bacterial infections (oral PCN) surgery: ➧controversial but remove if large, have sleep apnea, or repeated episodes ➧watch to bleeding: may end up in stomach; frequent swallowing; N/V ➧teaching: throat cultures, med compliance |
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Otitis Media Risks & Etiology
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risk factors: 6mon-2yo; winter; passive smoke; family Hx; daycare; male
etiology: bacterial; viral; eustachian tube age variation; allergies/emlarged adenoids/tonsils (can block EUtubes, blocking fluid) in kids: ➧EUStubes short, wide, straight: easier for fluid/bacteria/viruses ➧cartilage lining is underdeveloped ➧abundant pharyngeal tissue: blocks EUStube drainage ➧immature defense ➧supine positioning, pacifier use |
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Otitis Media S/S & Dx
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S/S:
➧pressure on eardrum ⇒ pain in middle ear ⇒ may pull at ear ➧irritability ➧fever ➧enlarged lymphs: esp behind ear ➧URI ➧anorexia Dx: ➧otoscope exam ➧sometimes culture discharge |
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Otitis Media Tx/Nsg Care
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72hr wait/see ⇒ mastoid bone infection possible
antibiotics antipyretics tubes for chronic OM prevention: upright for feeds teaching: followups; perforation (eardrum secretions ok); feeding upright; no 2nd hand smoke |
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Croup Syndromes
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infection & inflamm in larynx region
"barky" "brassy" cough sounds worse than actually is described according to primary anatomic area affected pts can last sickness for awhile and suddenly CRASH (usually after fatigue) |
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Acute Spasmodic Laryngitis
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etiology:
➧3mon-3yo ➧viral w/ allergen component repetitive w/ flares ➧sudden onset at PM when worse S/S: URI; Croupy cough; stridor (inhale, high pitch); hoarseness; dyspnea; restlessness; awakes w/ Sx/none in AM; tends to recur Tx: humidity (from hot shower, freezer's dry/cold air, outside) |
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Acute Laryngotracheobronchitis (Acute LTB) Etiology & S/S
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etiology:
➧viral ➧>5yo ➧follows URI ➧low grade fever if at all S/S: ➧mucous lining swells, airway narrows ⇒ struggles to breathe ➧cough ➧hoarseness ➧stridor ➧retractions ➧resp dist |
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Acute Laryngotracheobronchitis (Acute LTB) Tx/Nsg Care
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maintain airway/adequate gas exchange: bag, mask & O2 at bedside
close observation & assessment: esp w/ meds cool mist, cool temp therapy NPO until RR improved & - stridor; encourage drinking comfort, avoid agitation reassure parent about sound/illness meds: ➧Racemic epi aerosol: thru airslides method; worry for ↑HR & tremors ➧corticosteroids: inflam ➧heliox (He & O): for SEVERE |
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Acute Epiglottitis Etiology & S/S
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etiology:
➧very serious obstructive, inflam process ➧2-5yo ➧bacteria, but now more viral & older kids d/t immunizations S/S: ➧abrupt onset ➧fever, lethargy, dyspnea ➧agitated*, restless ➧drool*, can't swallow ➧no cough** ➧red throat, inflamm ➧tripod position (trying to get air in)* |
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Acute Epiglottitis Dx & Tx/Nsg Care
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Dx:
➧see practitioner for Xray Dx before checking throat when suspected to prevent occluding airway ➧Xray: swelling & airway at epiglottis Tx: ➧OR for artificial airway ➧antibiotics ➧corticosteroids ➧comfort ➧teaching: vaccinate at 2mon |
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Foreign Body Aspiration
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common: hotdogs, peanuts, grapes, popcorn, carrots; coins, buttons, earrings, balloons
S/S: ➧upper partial: cough, wheeze, stridor, dyspnea ➧upper complete: cyanosis, voice changes, retractions ➧lower: 1-sided wheezing, 1-sided diminished sounds, asymmetry of chest Dx: CXray or bronchoscopy Tx: ➧Heimlich for emergency ➧bronchoscopy ➧prep for test: IVF, empty stomach ➧PREVENTION & SAFETY |
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Bronchiolitis
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etiology: acute viral infection; winter/spring; RSV; spread by direction contact w/ resp secretions
patho: ➧epithelial cells in resp tract die ↳swelling, obstruction ↳acidosis 2ndary to air trapping & hyperventilation S/S: nasal discharge; tachypnea; resp dist; cough; irritability; dyspnea; crackles/wheezing Dx: rule out other diseases w/ S/S, age, season, community, epidemiology, Culture/ELISA for RSV Tx: ➧supportive care at home: fluids, monitoring resp status ➧hospital (d/t resp dist): mist therapy; IVF; possible NPO; Ribavirin (antiviral); resp assess (O2sat, ABG); contact precautions |
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Pneumonia Etiology & S/S
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pulmonary parenchyma ⇒ inflamed impairs gas exchange
etiology: virus, bacteria, aspiration event Viral: tachypnea; lowgrade fever; significant cough w/ coarseness; wheezing; crackles Bacterial: high fever; cough; rhonchi/crackles; chest/abd pain; retractions/nasal flaring; irritability; fatigue; not eating |
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Pneumonia Dx & Tx/Nsg Care
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Dx:
➧S/S b/c of presentation (bacterial more ill than viral) ➧chest radiology ➧sputum culture ➧CBC Tx: ➧antimicrobial therapy (bact) ➧symptomatic care ➧keep comfortable ➧hydration ad lib ➧resp assess ➧non-sedating cough med if irritable/not sleeping ➧watch for S/S pneumothorax (fever=serious phase) |
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Pertussis (Whooping Cough)
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Bordetella pertussis
etiology: <4 yo w/o immunization; ≥ 10 yo in US d/t boosters; direct contact or droplet spread, indirect with freshly contaminated articles S/S: ➧URI Sx ⇒ dry hacking cough** in PM ↳characteristic cough: whooping sound, cheeks flushed ⇒ cyanotic, eyes bulge, tongue protrudes continues until plug dislodged, emesis following attach ➧Infants < 6 mon: apnea ➧Older children: persistent cough & absence of whoop Tx: ➧resp precautions ➧bed rest during fever ➧ encourage fluids; small amounts frequently; refeed after vomiting ➧ high humidity ➧ Suction gently ➧ Careful monitoring of resp distress ➧ Family Tx/immunization d/t contagion |
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Bronchopulmonary Dysplasia (BPD) Etiology, Pathology & S/S
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etiology: Iatrogenic chronic lung disease ⇒ develops in premies from prolonged resp therapy ⇒ O2 injury & barotrauma (↑ventilator pressure)
patho: ➧+ inspiratory pressure, ↑O2 conc injure alveolar sacs & small airways ↳cystic areas & atelectasis ↳smooth muscle hypertrophy, bronchospasm, interstitial edema further aggravates airway obstruction S/S: ➧Resp Dist ➧Pulm edema ➧Neuro abnorms ➧Clubbing if severe |
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Bronchopulmonary Dysplasia (BPD) Dx & Tx/Nsg Care
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Dx:
➧PFT: see damage in tissue ➧CXR: see changes in tissue ➧ECG: trying to eliminate heart issues Tx: ➧PREVENT: ↓pressure/O2 ➧meds: surfactant (no evidence); Vitamin A; HFOV (mechanical ventilation that ↑RR & oxygenates blood changes tidal vol to ↑pressure) ➧Fluid restriction-pulm congestion or may hydrate to replace losses ➧↑calories: dense formula or supplemental feeds ➧Conserving O2 consumption ➧Promoting growth & development ➧pt receives Synagis to prevent RSV ➧Parent learms CPR |
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Cystic Fibrosis Patho & Dx
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patho:
➧Autosomal recessive trait ➧Exocrine gland dysfunction w/ multisystem involvement ➧↓ability of the epithelial cells in the airways & pancreas to transport Cl Dx: ➧Sweat Chloride test ➧Newborn Screening ➧Genetic testing ➧Abnorm nasal potential difference measurement |
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Cystic Fibrosis Manifestations
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Resp:
➧Thick bronchial mucus ⇒ bacterial colonization: have trouble moving mucous ➧↓O2-CO2 exchange: chronic hypoxia ➧Chronic cough: airways constantly inflam or very productive when moving ➧Dyspnea ➧Hyperaeration (barrel chest) ➧Clubbing ➧Sinusitis, nasal polyps GI: ➧Steatorrhea (fatty), azotorrhea (nitrogenous waste) ➧Intestinal obstruction: meconium ileus, distal intestinal obstruction syndrome: N/V, pain (complete or partial) ➧Failure to thrive: burn a lot of calories ➧Rectal prolapse ➧CF diabetes ➧Liver involvement: bile duct issues, portal HTN Skin: ➧Salty taste d/t ↑loss of Na & Cl: electrolyte replacement necessary if will sweat a lot ➧↑risk for hyponatremic and hypochloremic alkalosis ➧Edema d/t hypoalbuminemia: fluid leaks out of vessels ⇒ edema ⇒ skin breakdown Reproductive: ➧Females: Delayed puberty; ↓fertility; ↑incidence of premature labor, LBW ➧Males: sterile |
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Cystic Fibrosis Therapeutic Management
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Goals: Prevent/minimize pulm complications (bact, viral infections, pneumothorax); Ensure adequate nutrition for growth (calorie-dense); Encourage physical activity; Promote reasonable quality of life
Respiratory: ➧Pulm Hygiene: CPT** (loosens mucous), Vest, Flutter valve, exercise ➧Antibiotics ➧Nebulized/inhaled meds: Pulmozyme, TOBI, bronchodilators, anti-inflam ➧Cepacia precautions: a bacteria sometimes in CF pts' lungs ➧Lung transplant GI: ➧pancreatic enzymes w/ meals, snacks, enteral feedings ➧↑protein, ↑calorie diet, salt supplementation ➧fat soluble vitamins A, D, E, K w/ water-miscible forms ➧Monitor for & Tx intestinal obstruction |
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Pancreatic Enzyme Administration for Cystic Fibrosis Patients
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➧1-5caps per meal, fewer for snacks
➧caps can be taken whole, split, or sprinkled over small amt food at start of meal ➧amt enzymes depends on growth & amt of stools, amt of fat in food ➧should be taken w/i 30min of eating |
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Total Body Water over Age
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Newborns have more ECF than adults (75%-80% v 20-25%)
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Maintenance water balance
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insensible: water loss through resp tract & skin; no electrolytes
sensible: intermittent; stool & urine; included electrolytes |
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Fluid & Electrolyte Differences with Infants
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1. have expanded extracellular compartments: more water loss
2. ↑body surface area 3. ↑metabolic rate 4. kidneys more immature: harder time concentrating fluid & excreting wastes |
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Types of Dehydration (Sodium)
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1. isotonic (isonatremic): water & electro deficits in balance; most common; easiest to manage
2. hypotonic: electrolyte deficit > water deficit 3. hypertonic: water deficit > electrolyte deficit ➧hardest to manage ➧shock presents as neuro changes b/c fluid from inside cells to out maintain HR |
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Compensatory Mechanisms for Dehydration
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interstitial fluid movement:
➧responds to hemoconcentration & hypovolemia ➧fluid moves to intravascular space ➧vasoconstriction maintains pumping pressure kidneys: ➧reduce blood flow (↓urine) ➧↑serum osmolality (ADH & renin) |
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Nsg Care of F/E Disturbances
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observ: general activity, cry, etc
Hx: V/D, type, vol, #stools/diapers, weight loss/gain, behavior changes S/S: ↑HR, little turgor, RR, VS; weight QD Tx: PO fluids; IVF |
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Types of Shock
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1. hypovolemic: after ↓circulating blood vol from blood, plasma or ECF loss
2. cardiogenic: d/t impaired cardiac muscle Fx ⇒ ↓CO (final shock state) 3. distributive or vasogenic: d/t vascular abnorm ➧neurogenic: massive VD d/t loss of sympathetic NS tone (spinal cord injuries) ➧anaphylactic: d/t allergen hypersensitivity ➧septic: d/t overwhelming infection |
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Hypovolemic Shock
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S/S: same as adult except ↓BP as late sign
Dx: Hx & PE Tx: ventilator, cardiac support, vasopressor Nsg: good O2sat, IV access, place Foley, monitor VS/I&O/LOC/perfusion |
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Acute Diarrhea
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Tx:
➧correct F&E imbalances ➧PO fluids (better than solids): low sugar; milk ok ➧IVF for severe or if emesis ➧no meds unless really severe so kid can poop illness out |
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Chronic Diarrhea
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etiology: Hx viral infection; dietary restrictions; abx use (Cdiff)
patho: ➧impaired intestinal motility ➧excessive fluid intake ➧dietary fat restriction ➧CHO malabsorption (sorbitol, fructose) Dx: exclusionary Tx: ➧avoidance of certain foods/liquids ➧↑fiber, fat ➧limit fluid intake: b/c will give more diarrhea |
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Vomiting
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Dx: good Hx/descriptions (parents report more)
S/S: ➧classic presentation to vom & feel hungry right after (except w/ virus) ➧fatigued when VERY sick ➧HR does not improve right away ⇒ bolus Tx: ➧PO clear fluids ➧antiemetic meds given (high risk, b/c of surgery) |
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Severity of Burns
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1st degree: superficial; scalds, sunburn
2nd: partial thickness; can still blanch w/ pressure 3rd: full thickness; burn not painful b/c nerves died but associated 1st/2nd around it hurt 4th: down to/including bone |
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Area of Burn Wound (Pathology)
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edema:
➧injury to vessels causes caps permeability ➧VD causes ↑hydrostatic pressure in caps fluid loss: ➧no skin to hold moisture circulatory: ➧↓blood flow d/t fluid shifts ⇒ ↓CO & edema ➧thrombi |
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Systemic Consequences of Burns
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cardiovas (burn shock):↓CO d/t circulating myocardial depressant factor ⇒ ↓blood vol
renal: ➧renal VC occurs d/t loss intravas fluid ⇒ compensates w/ ↓UO ⇒ ↓renal plasma flow ⇒ ↓GFR ➧can result in renal failure GI: acid production stops; ↑metabolism d/t N loss g&d: delays in >40%TBSA burn for as long as 3yrs post |
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Major Burns Management
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airways (consider smoke damage):
➧establish airway ➧give 100% O2 ➧blood gas ➧bronchodilators fluid: ➧15%-20%+TBSA need Tx ➧crystalloid to keep electrolytes; colloids for protein & keeping fluids ➧cap refill, mental status & UO (Parkland) indicate adequate management nutrition:hypomet then hypermet; more protein & calories; supplemental feeds if >25% meds: abx, sedation & analgesia |
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Major Burn Wound Care
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wound: primary excision to reduce infection; debridement in OR allows new skin to grow
topical antimicrobial agents: silver nitrate; silver sulfadiazine; bacitracin biological skin coverings: allograft, xenograft, synthetic; permanent skin coverings (donor site more painful) |
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Developmental GI Differences
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↑metabolism
↑fluid & BSA ↓lactose but may outgrow ↓bile acid ⇒ ↓fat ↑permeability to hold protein = allergy issues that are outgrown liver immature in detox & processing waste ⇒ can get liver disease from TPN use ↓gastric emptying ⇒ diarrhea ↑acid ⇒ prone to ulcers |
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Cleft Lip & Palate
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patho: facial structures develop b/t 5th-9thwk gestation but don't fuse; can ID U/S
S/S: physical findings; uni or bilateral involvement Tx: surgery ➧lip repaired in 1st months of life ➧ palate repair variable 6-18mon long term: multidisciplinary team; speech issues; dental; inner ear probs; self-image |
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Pre- & Post-Op Care for Cleft Lip & Palate
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pre-op both:
➧feed w/ Haberman (little squeezes to aid sucking); some resp dist; some can breastfeed ➧reinforce positivity to parents for bonding post-op lip: ➧lip device: a bow to protect surgical site ➧restraints: "no-no"s ➧avoid prone position: might rub face; use carseat ➧aspiration precautions ➧suture line care: spray on site; bacetracin on steristrips ➧suctioning PRN on side of mouth ➧pain management: try to limit crying ➧parent edu post-op palate: ➧prone ok: helpful for post-op drainage in stomach ➧no hard items in mouth: soft nipple, breastfeeding ok ➧restraints ➧pain control ➧parent edu |
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Esophageal Atresia & Tracheoesophageal Fistula Patho, S/S & Dx
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patho:
➧defective separation or incomplete fusion of the tracheal fold ➧may have blind pouches or fistulas S/S: ➧frothy, drooling, can't pass feeding tube, abd distension, apnea, tachypnea after feeds ➧3 C's: coughing, choking, cyanosis Dx: ➧careful assessment before discharge ➧Hx polyhydramnios ➧bronchoscopy w/ endoscopy |
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Esophageal Atresia & Tracheoesophageal Fistula Pre- and Post-Op Treatment
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pre-op:
➧patent airway ➧supportive therapy: NPO (to protect lungs), NGT; ↑HOB; IVF; ABX (to protect lungs) ➧incubation to protect from saliva post-op: ➧reposition q2hr: often sedated & paralyzed ➧suction only w/ measured catheter ➧↑HOB ➧promote adequate nutrition b/c usually pt has feeding aversion d/t of long NPO status ➧pain control ➧family support |
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Omphalocele
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patho: failure of the abd wall to close; covered by peritoneal sac; usually w/ other anomalies (cardiac)
Dx: prenantally, 14wk |
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Gastroschisis
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patho: bowel herniates thru abd wall to right umbilical cord & thru rectus muscle; no sac; no other anomalies
Dx: prenatally |
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Omphalocele & Gastroschisis Pre- & Post-Op
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pre-op:
➧cover sac w/ saline gauze: slowly try to push contents back in while abd expands for ompha; bowel bag for gastro ➧prevent infection ➧careful positioning ➧NG ➧thermoreg: MUST MONITOR & PROVIDE INTERVENTIONS TO MAINTAIN NORMOTHERMIA post-op: ➧silo: sutured to edges of skin & suspended ⇒ gradual replacement of contents ➧returns to OR for complete skin closure |
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Congenital Diaphragmatic Hernia
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patho: opening in diaphragm thru which abd contents herniate into thoracic cavity ⇒ lung hypoplasia & heart issues from pressure
S/S: ➧acute resp dist upon dist ➧↓breath sounds on affect side ➧bowel sounds in chest ➧S/S of shock or compromised cardiac Dx: U/S in prenatal; Xray Tx: ➧resp support: intubation/hood O2; GI decompression (NGT, allows diaphragm to expand); NO bag mask; Semi-Fowler's ➧VS, IVF, calm enviro, family support |
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Anorectal Malformation
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S/S:
➧differs, anus not present ⇒ no passage of stool w/i 24hrs of birth ➧check for dimple, mec elsewhere, abd distension Dx: physical, Xray, U/S, etc Tx: stenosis (manual dilations), surgery, colostomy Nsg: ➧pre-op: ID, GI decompression, IVF, bowel prep ➧teaching: bowel training (scheduled hrs); diet (↑fiber & fluid); stool softeners (esp w/ stenosis); colostomy care; long term follow-up |
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GER & GERD
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S/S: emesis (feel better after); poor weight gain*; blood in emesis*; heartburn; gagging/choking; recurrent PNA* (reactive airway disease); esophagitis
Dx: Hx, pH probe, UGI/endoscopy Tx: ➧small thickened feeds ➧↑HOB ➧burping, sucking, no feeds before bed meds: antacids & histamine-receptor agonists/proton pump inhibitors (change pH); prokinetics (not proven) ➧fundoplication if cannot maintain airway |
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Hirschsprung Disease Patho, S/S & Dx
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patho:
➧no ganglion usually in rectum and proximal colon ↳accumulation of stool w/ distension ↳anal sphincter can't relax ↳enterocolitis S/S: V/D, explosive foul-smelling stools, abd distension, fever, lethargy, rectal bleeding, shock Dx: Xray, Ba enema, anorectal manometric exam, rectal biopsy |
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Hirschsprung Disease Tx/Nsg
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Tx:
1. temporary ostomy (w/i 6mon Dx) 2. pull-through procedure (reattach intestines together) Nsg: ➧pre-op: abd circumference; ↓fiber & ↑calorie/protein; NPO, IVF; colostomy teaching ➧post-op: assess anal area & device if some intestines removed; monitor stool output; NPO until +gas or +bowel sounds; NGT drainage & analyzation |
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Necrotizing Enterocolitis (NEC) Patho, Risks, S/S & Dx
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patho: anti-inflam of bowel
➧infant suffers GI tract vascular compromise ↳mucosal cells lining bowel damaged ↳↓blood supply to these cells results in ↑cell death ↳cells stop secreting mucus and thin bowel wall is attached by proteolytic enzymes ↳gas forming bacteria invade damaged areas & make gas there risks: ➧intestinal ischemia: esp after hypoxic event d/t ↓circulation to bowel ➧introduction to formula ➧overgrowth of bacteria S/S: abd distension; gastric retention; bloody stool (LATE sign); toxic look Dx: Xray of dilated loops of bowel; free air |
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Necrotizing Enterocolitis (NEC) Nsg
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check early: residuals, response to feeds, bloody stools
complete bowel rest (NPO, NG, IVF) abd xrays q4-6hrs acute phase blood cultures, ABX (septic risk) correct lytes imbalance surgery potentially |
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Short Bowel Syndrome (SBS)
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patho: reduced mucosal surface area d/t resection of small intestine
feeding: 1) TPN 2) then, enteral medical: ➧bacterial overgrowth: ABX ➧metabolic acidosis: ABX, low CHO formulas, citrate or bicarb ➧gastric acid: histamine-receptor antagonist ➧omegaven surgical: intestinal tapering, intestinal valves, or liver/small bowel transplant (bad) nsg: TPN leads to infections & liver disease d/t sugar content; prefer enteral feeds |
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Celiac Disease
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patho: can't digest gliadin (in wheat, rye, barley, oats) ⇒ toxic substances damages villi ⇒ malabsorption d/t reduced area
S/S: ➧frequent, bulky, greasy, smelly stools w/ frothy appearance ➧abd distention, emesis, anorexia ➧anemia, irritable, edema Dx: biopsy & wheat avoidance Tx: ➧gluten-free diet (corn, millet, rice) ➧fat-soluble vitamins, Fe, folic acid ➧family teaching |
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Intussusception
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patho: telescoping of intestine, obstruction of stool passage, inflam/edema/ischemia
S/S: ➧crampy abd pain that comes/goes ➧sausage-shaped mass ➧currant jelly-like stool followed by no stool Dx: assessment; Ba enema; Xray-KUB Tx: Ba enema (reduces obstruction) or surgery; stool after Ba mean improvement |
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Hypertropic Pyloric Stenosis
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patho: enlarged muscular tumor nearly obliterates pyloric channel
S/S: ➧regurgitating ⇒ projectile vomiting ➧appears hungry/irritable ➧late signs: dehydration, lethargy, lyte imbalance Dx:palpable olive-like mass; U/S; labs Tx (post-op): ➧IVF, NG ➧clear liquids ad lib ➧teach incision care ➧expect emesis ➧manage pain ➧monitor weight/feeds |
