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189 Cards in this Set

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What is hypospadias?
Congenital defect in which the urethral opening is not at the end of the penis but is located on the lower or underside of shaft. It is freq. associated with congenital chordee, a fibrous band of tissue that causes ventral curvature of the penis.
What are S/S of hypospadias?
1. Opening of the urethra at a location other than the tip of the penis
2. Downward curve of the penis (chordee)
3. Hooded appearance of the penis because only the top half of the penis is covered by foreskin
4. Abnormal spraying during urination
What are implications of hypospadias?
1. Difficulty urinating (will tend to splatter).
2. Different cosmetic appearance.
3. Curved penis (difficulty having intercourse, painful erections).
4. UTI's
5. Infertility (due to misplacement of urethral opening).
Why will hypospadias require treatment?
To enable child (as he grows older) to have a normal
1. sexual relationship
2. be able to urinate standing up.
3. normal appearance
What is the treatment of hypospadias?
Surgical correction.
When is surgery done for hypospadias?
Bone before the age of toilet training, between 6-15 months of age (b/c child will have difficulty with toliet training b/c urine is not eliminated through tip of penis) ALSO.. do procedure before child develops castration and body image anxiety.
Should circumcision be performed on a pt. with hypospadias?
No. b/c the foreskin may be used in surgical reconstruction of the defect.
Post-op priorities for hypospadias?
1. Penis may have a urethral stent or catheter in place (to maintain patency of the urethral opening while the meatus is healing) & be wrapped in a pressure dressing.
2. Encourage fluids to maintain adequate urine output & maintain patency of stent.
3. Monitor urine for I/O & for cloudiness or foul odor.
4. Call physician if no urine output occurs for 1 hr, b/c there could be kinks in the urinary diversion or stent or obstruction by sediment.
5. Restraints may be needed to prevent accidental removal of stent.
What med therapy for hyospadias is reccomended?
Med therapy includes antibiotics until the stent falls out, Tylenol for pain, and anticholinergic such as oxybutynin (Ditropan) for bladder spasms.
What client teaching for hypospadias should be performed?
1. Avoid giving child a tub bath until stent, if present, is removed.
2. Double diaper child to protect stent.
3. Limit activity for 2 weeks.
3. Restrict activities that put pressure on the site (riding toys, sitting on lap)
4. Give meds
5. Maintain adequate fluid intake & monitor for S/S of infection.
6. Call Dr. if urine leaks from anywhere but penis (urine will be blood tinged for several days).
7. Avoid contact with other children who may be infectious.
What can you admin to pt to help prior to hypospadias surgery?
Why?
male hormones to achieve bigger penis to help surgery
What is one way to identify boy with hypospadias?
abnormal urinary stream
If admitted for surgery of hypospadias, what do you assess?
child's perception of surgery and
what he calls his penis
How do you prepare child for hypospadias surgery?
use doll and put bandage and catheter on its penis (remind that penis is still there
What terms do you want to avoid for kid going into hypospadias surgery?
'cut off'
What do you do if pre-op med is IM for child?
mention it shortly before giving (less time to worry)
What are 3 NI post-op for hypospadias?
1. check urine CCA
2. assess visible penis
3. Teach parents
Why cath hypospadias child?
x3
1. keep area dry
2. promote healing
3. maintain patency of new urethra portion
What are two charact. of urine post-op hypospadias that should be noted?
What might they mean?
hematuria or cloudiness,
could mean unexpected bleeding or exudate
What color and consistency should urine be post-op hypospadias?
clear yellow
What two charact of penis might you expect post-op hypospadias?
1. some edema
2. misshapen if 1st of 2 surg
What behavior can you expect from kid post-op hypospadias?
Why might he do that?
shows everyone dressing,
reassures him penis is still there
What two things can you teach parents post-op hypospadias?
1. normal for kid to be preoccupied with penis
2. If parents show matter-of-fact-ness about it, should decrease gradually
What does the following describe?:
the major alteration is an increase in the permeability of the glomerular capillary wall to normal plasma proteins (esp. albumin)
nephrotic syndrome
When might you see severe proteinuria (albuminuria) and v serum albumin?
nephrotic syndrome
What do the following sym describe?:
pale, lethargic, anorexic, irritable, v activity tolerance; edema w/ ascites and wt gain; urine dark, frothy, v volume, ^ spec gravity, 4+ protein
nephrotic syndrome
What are the observable sym of nephrotic syndrome?
(skin color, activity x2, intake, mood)
pale, lethargic, anorexic, irritable, v activity tolerance
What's fluid balance sym r/t nephrotic synd?
edema w/ ascites and wt gain
What is urine like in nephrotic syndrome? x5
dark, frothy, oliguria, ^ spec grav, 4+ protein
What might there be a hx of r/t neph synd?
recent infection
What do you check every shift when managing neph synd?
edema
How often do you monitor edema r/t neph synd?
q shift
edema in kids, assoc w/?
nephrotic syndrome
Where is there often some edema r/t neph synd?
face (esp. eye)
Puffy eyes in AM, assoc w/?
nephrotic syndrome, and
glomerulonephritis
What might you see despite poor appetite r/t neph synd?
wt gain (edema)
What does BP show in neph synd?
normotensive or slightly hypotensive
Differentiate BP in glomeruloneph and neph synd?
glom neph: high BP
neph synd: low BP (or normal)
What's the best amount of activity and best position on initial Rx for neph synd?

h
complete bedrest,
upright position
don't move, but don't lay on your kidneys either, don't lay down at all
What are 2 things to implement r/t diet for acute neph synd?
high protein,
small freq feedings
What's the drug of choice for neph synd?
prednisone- give 2 mg/kg/day
When should proteinuria go away during neph synd tx?
7-21 days
Give prednisone w/ or w/o food?
give w/ food or milk
What happens as immunoglobulins are lost in urine r/t neph synd?
What do you avoid?
susceptible to infection,
avoid infected people
Why are pt w/ neph synd susceptible to infection? x2
immunoglobulins (proteins) lost in pee,
steroids mask s/s of infections
How do you prevent skin breakdown r/t edema?
opposing skin surfaces kept clean and separate
What topic do you teach about in D/C teaching r/t neph synd?
relapse
How often neph synd relapse?
2-4 x a year for years
What do you do to detect early exacerbation r/t neph synd?
How often?
test for protein in pee
at least 2x a week
How do you treat neph synd relapse or if sensitive to steroids?
immunosuppressant ex Cytoxan
When would you use Cytoxan in neph synd Rx?
if sensitive to steroids and
during relapse
How does nephrotic syndrome present?
1. Gradual onset of massive edema, starting as periorbita (surrounding eyes) l then shifting to abd. and extremities; dramatic weight gain and abd. pain results.
2. Secondary-- irritability, malaise, anorexia
3. proteinuria
What are S/S of nephrotic syndrome?
1. Child gains weight
2. Periorbital and facial edema most prominent in the morning.
3. Leg, ankle, labial, or scrotal edema.
4. Urine output decreases;urine is dark and frorthy.
Ascites
5. BP normal or hypertensive (rare)
6. Lethargy, anorexia, pallor
7. MASSIVE proteinuria
8. Decreased serum protein (hypoproteinemia) and elevated serum lipid levels.
What are nursing concerns for nephrotic syndrome?
1. Reduce excretion of urinary protein.
2. Maintain protein-free urine.
3. Reduce edema.
4. Prevent infection
Nursing priorities for nephrotic syndrome?
1. Monitor vitals; I/O, daily weights. Measure Abd. girth.
2. Monitor urine for specific gravity and protein.
3. Monitor for edema.
4. A regular diet w/o added salt is prescribed if child is in remission; sodium is restricted during periods of massive edema (fluids may be restricted also).
5. Fluids not usually restricted.
6. Prevent skin breakdown, turn and reposition often; use special mattresses to prevent breakdown keep skin dry and clean.
7. Prevent infection; handwashing, restrict infectious visitors; not kept in hospital after dx. to reduce exposure to organisms; encourage diet to replace lost protein.
What medications may be prescribed for nephrotic syndrome?
1. Corticosteroid therapy; monitor for S/S of infection and adverse effects. **reduces inflammatory process, which reduces proteinuria & edema quickly **7-21 days
2. Immunosuppresant therapy to reduce relapse rate and induce long term remission (if steroids don't work, therapy may be given along with the steroid).
3. Diuretics to reduce edema.
4. Plasma expanders such as salt-poor human albumin may be prescribed.
5. Antibiotics-- for any infection
What are S/S of steroid therapy?
1. Impaired wound healing.
2. Hyperglycemia
3. Skin fragility
4. Abnormal fat deposition
5. Emotional lability
6. Hirsutism, moon facies
7. Osteoporosis.
8. Increased risk of infection (steroids mask infection, and lower WBC count)
Diet for nephrotic syndrome?
Low protein, low salt (sodium), low fats, high CHO.
How will you know if treatment for nephrotic syndrome is successful?
1. Less protein in urine.
2. Free of S/S of infection.
3. Edema gradually goes down.
4. Diuresis
What do the following describe?:
an antigen-antibody reaction that follows an infection caused by group A beta-hemolytic step (not ARF)
Acute glomerulonephritis
What precedes acute glomerulonephritis?
group A strep infection
What are two examples of group A strep that can cause Acute Glom neph?
strep throat,
impetigo
What might the following signs indicate?:
- hx of URI or skin infection
- cola urine
- eye edema
- loss of appetite
- ^ temp
- ^ BP
acute glom neph
What are the nsg ass of acute glom neph? x6

h
- hx of URI or skin infection
- cola urine
- eye edema
- loss of appetite
- ^ temp
- ^ BP
hx,
pee,
face,
nutrition,
2x vs
How recently would pt have had URI or impetigo before acute glom neph?
1-3 wks
3 words describing pee colorf in glom neph?
cola, tea, smoke
When is eye edema worse in glom neph?
AM
What can temp reach in glom neph?
104 deg
What's imp to assess freq with glom neph?
BP
What's a major complication of glom neph?
hypertensive encephalopathy
When is hypertensive encephalopathy an issue with glom neph?
during acute phase,
if BP high and
output poor
What can hypertensive encephalopathy result in with glom neph (general and specific)?
x4
neuro sym:
dizzy, h/a (headache), photophobia
What are visible s/s r/t urine in glom neph?
x2
oliguria,
hematuria
What do u/a say if glom neph?
+ albumin, RBC, WBC, casts, ^ spec grav
What lab value differentiates glom neph from nephrotic synd?
u/a + for RBC
What blood lab values indicate glom neph?
^ BUN,
^ ESR,
^ Creatinine,
ASO titer ^
What is the most spec lab value for renal failure?
^ creatinine
What's activity during acute glom neph?
bedrest
Protect from what in acute glom neph? (r/t temp, activity, & precautions)
x3
chilling,
fatigue,
infections
How often check vs in acute glom neph?
q 4 h
Report what two things in acute glom neph?
^ BP, and
s/s cerebral ischemia
Glom neph, if marked edema or ^ BP, do what r/t diet?
moderate Na restriction
Glom neph, if severe kidney involvement, do what r/t diet?
may limit protein
Glom neph, if output way down, do what r/t diet?
restrict fluids (ice chips)
D/C teaching, what two things r/t
1. avoid or treat any resp or skin infections
2. avoid fatigue and sports (until neg labs for hematuria or proteinuria)
Why does AGN occur?
1, It is acute inflammation of the glomeruli.
2. Acute post-infectious glomerulonephriitis is preceded by a strep infection, usually of the skin or resp. tract.
3. Damage is caused by an antigen-antibody complex that lodges in the glomeruli. An overproduction of antibodies stimulated by the infection may eventually settle in the glomeruli, causing inflammation. .
What are S/S of AGN?
1. edema
2. hematuria
3. reduced urine output
3. lethargy & anorexia.
4. High BP= increased head ache
5. decreased LOC
6. convulsions
What are lab results of AGN?
1. ^ BUN
2. ^ ESR = inflammation in body
3. ^ ASO (antistreptolysin O) = previous strep infection
4. Decreased H&H (hemoglobin and hematocrit) due to blood loss in urine
4. renal ultrasound sounds enlarged kidneys.
5. hematuria, proteinuria, and RBC casts in urine.
6. Serum samples show ^ azotemia (nitrogenous waste in blood) ^ CR, and electro imbalance.
what are nursing Dx for AGN?
1. risk for excess fluid volume.
2. imbalanced nutrition
3. risk for injury RT hypertension and CNS involvement.
4. Activity intolerance
5. Diversional activity deficit
Nursing implications for AGN?
1. Bedrest during acute period.
2. Monitor fluids & electros
3. Measure I/O, weigh daily
4. maintain fluid restriction if ordered
5. Limit Na, K, and protein
6. Monitor dietary intake to optimize calories consumed.
7. Provide skin care to limit effects of edema and lethargy
8. Monitor vital signs including mental status, report ^ BP and deterioration of mental status immediately.
Medication therapy for AGN?
(to treat hypertension and prevent CNS involvement, and to get rid of infection *if infection is causing it)
1. antihypertensives, such as hydralazine (Apresoline)
2. Diuretics (lasix)
3. Anti-biotics
How to differentiate between AGN and nephrotic syndrome?
Here's my best explanation:
They are very similar, but the cause of the edema is different.

Glomerulonephritis is caused by immune complexes that deposit in the basement membranes of the glomeruli, which makes them edematous and infiltrated with leukocytes. This causes capillaries to occlude, basically resulting in water and sodium retention. Because interstitial fluid volumes are increased, the circulatory system becomes congested = edema.

Nephrotic syndrome is caused by the glomeruli becoming permeable to albumin --> leads to proteinuria --> hypoproteinemia --> decreased oncotic pressure --> edema.

Acute glomerulonephritis is a result of a streptococcal infection. It typically presents weeks after the infection has cleared, but is a direct result of the infection. Nephrotic syndrome has many causes from disease of the kidney to a condition that has affected another part of the body (like Hep B or diabetes mellitus).
How to differentiate nephrotic and AGN?
Nephrotic Syndrome
Cause: Glomerulenpehritis, drugs, damage, diabetes

Signs:
PROTEIN in the urine.
Edema (general)
"Foamy urine"
hypotension
Low urine output
Hypoalbuminemia
Hyperlipidemia

Treatment:
Find & treat cause (ex antibiotics for infection
Control B/P
Diuretics
Steroids
Reduce cholesterol
How to differentiate nephrotic and AGN?
AGN
Cause: Inflammation of the glomeruli usually due to bacterial infection

Signs:
BLOOD in the urine
Edema (general)
“Foamy urine”
Hypertension
Low urine output
Hyperlipidemia
Nausea/Vomiting
Fever
Rash

Treatment:
--Find and treat cause (ex antibiotics for infection)
--Control B/P
--Diuretics
--Corticosteriods
--Reduce cholesterol
General nursing care for these diseases?
General Nursing Care

Low Protein, Low Salt diet
Strict I’s and O’s
Fluid Restriction
Bed Rest
Daily Weights
Urinalysis (will see elevate BUN and Creatinine)
Both conditions may require a kidney biopsy
Protect clients b/c they are immunocompromised
How does nursing care differ between nephrotic syndrome and AGN?
AGN

1. prevention measures (treatment of strep infection) and management of hypertension (meds, dietary salt restriction, monitor BP freq).

**Not chronic in nature,CAN BE PREVENTED by strep meds, no distortions in body image

Nephrotic syndrome
1. Parent education regarding S/S, treatment regimes, disease chroniciity, behavioral changes regarding distorted body imaged secondary to massive edema and weight gain.

** can NOT BE prevented, distortion in body image, coping skills and treatment regimens necessary for long term management.
What is hemolytic uremic syndrome (HUS)?
Hemolytic-uremic syndrome (HUS) is a disorder that usually occurs when an infection in the digestive system produces toxic substances that destroy red blood cells, causing kidney injury.
What is HUS caused by?
Abnormal response to a virus/illness/food contaminate (E. Coli**) in the GI tract that causes acute renal failure

The arterioles and capillaries of the body become obstructed by the resulting complexes of activated platelets which have adhered to endothelium via large multimeric vWF. The growing thrombi lodged in smaller vessels destroy red blood cells (RBCs) as they squeeze through the narrowed blood vessels, forming schistocytes, or fragments of sheared RBCs.
What are S/S and typical presentation of HUS?
Early symptoms:

Blood in the stools
Irritability

Fever
Lethargy
Vomiting and diarrhea
Weakness

Later symptoms:
Bruising & Bruising **KEY S/S!!!
Decreased consciousness
Low urine output
No urine output
Pallor (due to anemia) ** LOW H&H, high reticulocyte (RBCs that are forming to become mature, they are immature).
Seizures -- rare
Skin rash that looks like fine red spots (petechiae)
Yellow skin (jaundice)

Typical presentation: History of gastro or URI now with sudden onset of, unexplained bleeding/bruising and renal failure
What is a diagnosis of HUS?
Diagnosis-anemia, thrombocytopenia, and renal failure (elevated BUN/creatinine, proteinuria, hematuria) triad
Labs of HUS?
BUN and CR elevated, H&H decreased.
Treatment for HUS?
1. Dialysis (3-8 hrs x 3 days/week)
2. Blood product transfusions as necessary (to treat anemia.. administer with caution to prevent fluid overload).
3. MAINTAIN NORMAL ELECTROLYTE & Fluid BALANCE, CBC, AND OUTPUT *dialysate solution *if child is anuric, fluid restrictions may be prescribed.

Most recover completely, if found early and no secondary problems were present
How do know if treatment for AGN is working?
If there is urine output!
Is nephrotic syndrome acute or chronic in nature?
Chronic.
Is AGN acute or chronic in nature?
Acute.
What is Wilm's tumor?
Wilms' tumor is a rare kidney cancer that primarily affects children. Also known as nephroblastoma, Wilms' tumor is the most common cancer of the kidneys in children. Wilms' tumor most often affects children ages 3 to 4 and becomes much less common after age 5.

Wilms' tumor most often occurs in just one kidney, though it can sometimes be found in both kidneys at the same time.
Symptoms of Wilm's tumor?
Wilms' tumor doesn't always cause signs and symptoms. Children with Wilms' tumor may appear healthy, or they may experience:

Abdominal swelling
****An abdominal mass you can feel (Firm, nontender, abdominal mass confined to one side of the abdomen)
Abdominal pain
urinary retention, hematuria, or both!
Fever
Blood in the urine
anemia (caused by hemorrhage within the tumor)
Pallor, anorexia & lethargy *resulting from anemia
Hypertension (caused by secretion of excess amounts of renin by tumor)

**Saunders pg. 530-531
Nursing considerations for Wilm's tumor?
Avoid palpation of the abd. in a child and be cautious when bathing, moving, or handling the child. It is important to keep the encapsulated tumor intact. Rupture of the tumor can cause cancer cells to spread throughout the abd, lymph system & bloodstream.
What is type 1 Diabetes?
Characterized by destruction of pancreatic beta cells, which produce insulin
Why is it a misnomer to say “juvenile onset”?
*Juvenile onset diabetes type 1- Has gone far away, because we now see Type 2 Diabetes in Children.
Treatment for diabetes?
1. Nutrition- 3 balanced meals/day, eat at regular intervals, plus a mid afternoon snack and bed time snack, need consistent CHO, protein, and fats at meals
2. Exercise- eat extra foods for increased activity, monitor blood

Insulin therapy

Glucose monitoring: goal range
80 to 120 mg/dl

Lab measurement of hemoglobin A1c

Urine testing for ketones

Not routinely used except to test q3h during illness and whenever glucose is ≥240 mg/dl when illness not present

Teach patient and family how to manage hypoglycemic episodes

Illness management

Management of DKA
What is diabetic ketoacidosis (DKA)?
This is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Ketoacidosis is the name for your body's state when it has started producing ketones, a high level of ketones causes the ph (acidity) of the blood to raise and this can cause coma and death in anyone.

OR (another explanation)

Diabetic ketoacidosis is a problem that occurs in people with diabetes. It occurs when the body cannot use sugar (glucose) as a fuel source because there is no insulin or not enough insulin. Fat is used for fuel instead.

Byproducts of fat breakdown, called ketones, build up in the body.
What's the most imp post op assessment for shunt r/t hydrocephalus?
^ ICP
If shunt for hydrocephalus, what position?
position flat or side-lying (to avoid to rapid decompression of IC fluid)
What's the most important assessment pre and post op r/t myelomeningocele?
^ ICP
What position do you put kid in w/ hydrocephalus r/t Myelomeningocele?
prone,
elevated head (to reduce ICP)
What 2 sym indicating what 2 neurological changes can you assess r/t myelomen?
1. bulging anterior fontanel (= ^ ICP)
2. high pitched cry (neuro damage)
How can hydrocephalus present in the eyes?
sunset eyes - eye rotated downward
What might be the first sign before neuro sym in myelomeningocele?
How do you detect it?
hydrocephalus,
head >1" larger than chest
What sym do 90% of pt w/ myelomeng. get?
hydrocephalus
S/S of increased ICP?
Early signs:

1. slight change in vitals.
2. slight changes in LOC.
Infant: irritability, high-pitched cry, bulging fontanel, increased head circumference, dialted scalop veins, Macewen's sign (cracked-pot sound on percussion of head), setting sun sign (sclera visible above the iris).
Child: headache, N/V, visual disturbances (diplopia), seizures.
S/S of increased ICP?
Late signs:
1. decrease in LOC
2. bradycardia
3. decreased in motor and sensory responses
4. alteration in pupil size and reactivity
5. decorticate (flexion posturing)
6. Decerebrate (extension posturing)
7. Cheyne-Stokes Respirations
8. Coma
What are four major types of ICP monitors?
1. Intraventricular catheter (allows continuous drainage) A drainage bag is attached to the system is kept at the level of the ventricles and can be lowered to decrease ICP.
2. Subarachnoid bolt (Richmond screw)
3. Epidural sensor
4. Anterior fontanel pressure monitor
Nursing considerations for increased ICP?
1. Monitor airway; administer O2.
2. Assess injuries.
3. Elevate HOB 30 deg., Position client so that the head is maintained midline to avoid jugular vein compression (can ▲ ICP)
4. Monitor vitals and neuro (assess LOC closely).

TEMP- often elevated
Pulse- variable, may be rapid. slow & bounding, or feeble.
BP- normal, elevated, or shock levels.
R- slow, deep, irregular
Eyes- fixed and dilated.

5. Keep stimuli to a minimum, minimize crying in infant.
6. Withhold sedating meds, so that LOC can be assessed.
7. Seizure precautions (pad and raise side rails!)
8. Monitor for ▼ response to pain ( a sign. sign of altered LOC)
9. Maintain NPO status or provide clear liquids until it is determined that vomiting will not occur.
10. monitor IV fluids to avoid aggravating any cerebral edema and to minimize the possibility of over hydration.
11. Monitor for a fluid or electrolyte alteration (could indicate injury to hypothalamus or posterior pituitary).
12. Assess wounds & dressings for drainage, as well as the nose or ears. (May indicate leakage of CSF)
13. Administer tepid sponge bath or place the child on a hypothermia blanket to reduce temp.
14. Avoid suctioning the nares. (catheter might enter the brain through fracture, which places child at risk for infection).
15. Give tylenol for headache, anticonvulsants for seizures, antibiotics for laceration if present; prepare to administer prophylactic teanus toxoid.
16. Give steroids or osmotic diuretic to reduce cerebral edema.
17. Monitor for signs of brainstem involvement (deep, gasping resp, wide fluctuations in pulse, widening pulse pressure, etc).
18. monitor for signs of epidural hematoma; asymmetrical pupils (one dilated, nonreactive pupil).

**If drainage from nose or ear is tested positive for glucose, notify the Dr.! You must test the drainage. If positive for glucose, indicates CSF leakage.
**Prevent straining, such as during coughing, vomiting or defecating.

*Normal ICP- <10, Elevated 10-20, Serious >20
Positioning for ICP? Do's and Don'ts?
- Positioning and Treatments:

i. Sit the patient up - It helps lower the ICP.

ii. Lie the patient down. It helps the cerebral perfusion.

- Don’ts in relation to positioning and treatment:

i. don’t lift the patient’s legs up unnecessarily
ii. don’t position the patient on her side
iii. don’t flex her neck
iv. don’t repeatedly go at the patient with tasks to be done
v. avoid increased intrathoracic pressure (avoid coughing, straining, & extreme hip flexion).

- Do’s:

i. touch and massage the patient – but monitor the effects.
ii. let family visit and speak to the patient – but monitor the effects.
iii. try to get things done and then let the patient rest.
What is an EVD?
external ventricular drainage.
Nursing considerations for an EVD?
If unclamped for CSF drainage, carefully monitor the level of the collection container. If the container is too low, improper CSF decompression could lower ICP too rapidly, causing bleeding and pain.
Why does ICP rise or fall?
- Something blocks the normal drainage of csf
- Bleeding inside the head
- Edema (there are a couple of kinds, but both will make the affected tissue swell)
- “Mass effect” – something’s in there that shouldn’t be, and it’s taking up space where there isn’t any. If it’s big enough it can shove the brain over to one side, producing a “shift”.
Reasons for ICP to drop?
-Anything, basically, that reverses one of the processes just listed:

csf not draining? – drain some off!

Bleeding inside the head? Take out the clot!

Got edema? Do the mannitol thing, (mannitol is a hyperosmoltic diuretic.... will shrink the brain cells and then pee the ICP out!)

and so on. Obviously, the treatment is going to vary with the cause.
What is meningitis?
It is an infectous process of the central nervous system caused by bacteria or viruses that may be acquired as a primary disease or a result of complications of neurosurgery, trauma, infection of the sinuses or ears, or systemic infections.
DX of meningitis?
Testing CSF obtained by lumbar puncture; the fluid is cloudy with increased pressure, increased WBC, elevated protein, and decreased glucose levels.
What is bacterial meningitis?
Caused by various organisms; most commonly Haemophilus influenza type B, strep mneumoniae, can be transmitted by droplets from nasopharyngeal secretions.
What is viral meningitis?
Assocaited with virusrs such as mumps, paramyxovirus, herpesvirus, and enterovirus.
What is the difference between these two types of meningitis?
Viral meningitis is usually less severe and resolves without special treatment. Many different viruses can cause meningitis. Most of them are more common during the summer and fall months.Bacterial meningitis is extremely serious. It may result in brain damage, hearing loss or learning disability. It is important to know which type of bacteria is causing the meningitis
S/S of meningitis?
classic: high fever, severe headache, vomiting, and stiff neck ***Purple rash!!

-- they tend to cry uncontrollably, refuse to eat, or be inactive
Interventions for meningitis?
1. Provide resp. isoloation precautions and maintain it for least 24 hrs after antibotics are given.
2. Administer antibotics and antipyretics as prescribed (give antibiotics after lumbar puncture); antiseizures meds may be given too.
3. Assess for pain, give pain meds, narcostics should be avoided b/c ^ ICP can be masked by narcotics.
4. Perform neuro assessment and monitor for seizures, hearing loss & visual alterations; mental retardation, cerebral palsy, and hydrocephalus may occur; complication is meingococcemia, a septic infection that can lead to circulatory collapse and tissue necrosis.
5. assess for complication of inappropriate ADH secretion, causing fluid retention (cerebral edema) and dilutional hyponatremia; **Urine output & serum sodium will decrease!! restrict oral fluids and monitor IV fluids to prevent fluid overload.
5. Assess for changes in LOC and irriability.
6. Monitor for purpuric or petechial rash (meingococcal infection).
7. Assess nutrtional status, monitor I/O
8. Monitor for hearing loss.
9. Determine close contacts of the child; contacts may need prophylactic teratment
10. Pneumococcal conjugate vaccine is recommended for all children beginning at age 2 months to protect again meningitis; streptococcal pneumocci can cause many bacterial infections including meningitis.

1. Provide an environment that will minmize ICP elevation; elevate HOB 15-30 deg, avoid neck extension or flexion, maintain head in neutral position; keep environment quiet and subdued.
2. Viral meningitis is treated symptomatically; usually only infants are hospitalized for viral meningitis.

*pg. 138 hogans book
Medication therapy for meningitis?
Treated with IV antibiotics for 7-14 days; get the vaccine to prevent infection! Contacts with the infant may receive Rifadin prophylactically.
What occurs in Reyes syndrome?
Reye's syndrome is a potentially fatal disease that causes numerous detrimental effects to many organs, especially the brain and liver, as well as causing a lower than usual level of blood sugar (hypoglycemia). The classic features are liver damage (fatty liver), cerebral edema, aspirin use and a viral infection.

An acute metabolic encephalopathy of childhood; fatty degeneration of liver leads to liver dysfunction.

Metabolic encephalopathy is temporary or permanent damage to the brain due to lack of glucose, oxygen or other metabolic agent, or organ dysfunction. Most cases occur when the liver cannot act normally to remove toxins from the bloodstream during an acute illness, but it can also be caused by a toxic overdose, or other systemic disease.
What causes Reyes syndrome?
While exact etiology is unclear, it usually develops after a mild viral illness such as chickenpox. Research has linked the development of Reye syndrome to the use of ASPIRIN.

As soon as parents used only acetaminophen or ibuprofen, incidence of Reye syndrome decreased!
What should you teach parents to avoid Reyes syndrome?
Avoid aspirin; use acetaminophen (Tylenol) or ibuprofen instead!
What tests are performed for Reye's syndrome?
Liver function tests (do a liver biopsy) blood coagulation tests done.

Liver enzymes and ammonia= Up
Blood glucose= down
PT= prolonged (likely to bleed)
Bilirubin= normal
Liver biopsy= fatty deposits
Watch for acidosis.
What is hydrocephalus?
Syndrome resulting from imbalance of CSF absorption or CSF production resulting in head enlargement and increased ICP.
Water on the brain!!

Cause
Congenital
Acquired

*communicating- impaired absorption of CSF (goran not listening)
non-communicating- obstruction (can't go through)!
How is hydrocephalus treated?
Surgical insertion of a tube or shunt into ventricles with the end in either the peritoneum or atrium; the most common version is ventriculoperitoneal;

Preop-- monitor child for increased ICP
POST- position child flat and on unoperative side; if held, it is important not to allow the head to be elevated.
What do you need to teach a family with a child with hydrocephalus?
1. Teach caregiver S/S of shut infection and malfunction and what actions to take should symptoms develop.
2. Some children with hydrocep. have brain damage that results in motor, language, perceptual, and intellectual disabilities; parents may need referrals to early intervention professionals to provide long term rehabilitation services.
3. May have increased risk of latex allergies; teach parents to avoid nipples. pacifiers, and toys made out of latex products.
S/S of shunt malfunction in infants and toddlers?
Infants: cranial suture lines have not fused; increased head circumference, high-pitched cry, bluging fontanel, irrability when awake, seizures.

Child: vomitting, irritability and headache; setting sune yes, seizures, papilledema, decreased LOC, change in vital signs (increased BP and widening pulse pressure) occur

Older children have difficulty with balance/coordination.
All children have lethargy and Cheyne-Stokes respirations.
What long term management/care is required?
Hydrocephalus is a life-long problem and the child will require evaluation on a regular basis. Parents should know how to recognize signs that indicate shunt malfunction or infection and how to pump the shunt.
What scan will they use for hydrocephalus?
Most likely CT scan-- it is faster!
Medications and treatment for Hydrocephalus?
Medications
Diuretics – decrease CSF production
Anticonvulsants- limit seizure activity
Antibiotics – tx any infection if present

Treatments ventricular tap and/or EVD until shunt insertion
What are seizures?
Seizures are alterations in firing of neurons in brain; is the result of cortical neuronal discharge; the result of this discharge (seizure activity) depends on where in brain discharge begins and how it spreads.
What are common causes for acute children?
Acute-- associated with acute insult.

Head trauma
meningitis
febrile episodes,
hypoglycemia ,
hypocalcemia,
bacterial toxins (such as shigella), alcohol withdrawal,
environmental toxins,
electrical shock,
and side effects of medication.


**How do you know if having a true seizure? Post-icial= they cannot remember it.
What are common causes for chronic seizures in children?
Chronic causes for epilepsy include genetic epilepsy (benign rolandic, absence and juvenile myoclonic epilepsies are some examples), congenital brain malformation associated with some neurocutaneous disorders (tuberous sclerosis, neurofibromatosis), migrational defects (where gray matter migrates to the wrong brain region during early development.
Nursing concerns during a seizure?
1. Ensure airway patency (position on side and head down).
2. Have suction equipment and O2 available.
3. If the child is standing or sitting, ease the child down to the floor and place in a side-lying position.
4. Place a pillow or folded blanket under child's head; if not available, place your own hands under the head or place child's head in your lap.
5. Loosen restrictive clothing.
6. Remove eyeglasses.
7. Clear the area of any hazards/objects.
8. Allow seizure to proceed and end w/o interference.
9. if vomiting occurs, turn child to side as a unit.
10. DO NOT RESTRAIN, PLACE ANYTHING IN MOUTH, OR GIVE ANY FOODS/LIQUIDS.
11. Give meds/remain with the child until he fully recovers.
12. Observe for incontinence
13. Document and TIME the seizure!
Seizure precautions?
1. Raise side rails when child is sleeping.
2. Pad side rails and other hard objects.
3. instruct child to use protective helmet when outside playing.
4. place water-proof mattress or pad on bed or crib for incontinence during seizure.
What are some common seizure medications? (see pg. 968 Saunders book).
1. Amobarbital (Amytal)
2. Carbamazepine (Tegretol)
3. Clonazepam (Klonopin)
4. Ethosuximide (Carontin)
5. Ethotoin (Peganone)
6. Lorazepam (Ativan)
7. Mephobarbital (Mebaral)
8. Phenobarbital (Luminal)
9. Phenytoin (Dilatin)
10. Diazepam- Valium (increases threshold of seizure).

Meds are teratogenic– harmful to pregnant teenagers. Make sure they are on birth control.

**Ketogenic diet -- High fat, adequate protein, low CHO.
Why do get levels of seizure drugs?
Since people can become more sensitive to medications as they age, they may need to have their blood levels of medication checked occasionally to see if the dose needs to be adjusted. The effects of a particular medication also sometimes wear off over time, leading to an increase in seizures if the dose is not adjusted. People should know that some citrus fruit, in particular grapefruit juice, may interfere with breakdown of many drugs. This can cause too much of the drug to build up in their bodies, often worsening the side effects.
What is a "loading dose?"
A loading dose is an initial higher dose of a drug that may be given at the beginning of a course of treatment before dropping down to a lower maintenance dose.[1]

A loading dose is most useful for drugs that are eliminated from the body relatively slowly. Such drugs need only a low maintenance dose in order to keep the amount of the drug in the body at the appropriate level, but this also means that, without an initial higher dose, it would take a long time for the amount of the drug in the body to reach that level.

Phenytoin for acute status epilepticus should also be given with an initial loading dose, co-administered with a benzodiazepine, to immediately stabilize neuronal membranes and electrical activity during a seizure.

http://en.wikipedia.org/wiki/Loading_dose
What do you have to watch for with a loading dose?
Respiratory depression. NOTE: Higher doses have to be given over a longer time!
Common Bacterial skin problems?
Impetigo---
Staphylococcus bacteria
Break in skin barrier
Vesicle: ruptures easily
Crusts: honey color
Spreads easily
Antibiotic ointment

Folliculitis---
Pimple – infection of hair follicle
Furuncle – Boil
Carbuncle – multiple boils
DO NOT squeeze
Antibiotic ointments

Cellulitis---
Inflammation of the skin
Antibiotics
Soaks, compresses
Can be severe
Common viral skin problems?
1. Warts: Verruca
Difficult to treat

2. Plantar Warts: Plantar surface of foot

3.. Herpes Simplex
Type I: cold sore
Type II: genital

4. Molluscum contagiosum: umbilicated papules
Common fugal skin problems?
1. Tinea capitis: Scalp
2. Tinea corporis: Body, fingernails
3. Tinea cruris: “Jock itch”, thigh, scrotum
4. Tinea pedis: “Athlete’s foot”, toes, feet
5. Candidiasis: Candida
Diaper, Oral, Vaginal, Breasts, Skin Folds
Diaper Dermatitis
Impetigo?
Manifestations:
1. Begins as a reddish macule
2. Becomes vesicular
3. Ruptures easily, leaving superficial, moist erosion
4. Tends to spread peripherally in sharply marginated irregular outlines
5. Exudate dries to form heavy, honey- colored crusts
6. Pruritus common
7. Systemic effects—Minimal or asymptomatic
8. Common in hot, humid months.
9. May begin from open skin (bite, atopic dermatitis)
10. Located on mouth, nose, maybe hands and extremities

Management:
1. Careful removal of undermined skin, crusts, and debris by softening with 1:20 Burow solution compresses
2. Topical application of bactericidal ointment
3. Systemic administration of oral or parenteral antibiotics (penicillin) in severe or extensive lesions

Teaching
1. Contagious for 48 hr after antibiotic treatment begun.
2. Family members shouldn't share towels, washclothes, etc. Disinfect everything.
3. Use antibiotics for full length of treatment.
4. will tend to heal w/o scarring.
Folliculitis (pimple) ?
This is infection of the hair follicle

1. Skin cleanliness
2. Local warm, moist compresses
3. Topical application of antibiotic agents
4. Systemic antibiotics in severe cases
5. Incision and drainage of severe lesions, followed by wound irrigations with antibiotics or suitable drain implantation

Teaching:
1. Do not squeeze lesion!
2. Contagious.. will tend to heal with scar formation.
Cellulitis?
1. Inflammation of skin and subcutaneous tissues with intense redness, swelling, and firm infiltration
2. Lymphangitis “streaking” frequently seen Involvement of regional lymph nodes
common

Treatment
1. Oral or parenteral antibiotics
2. Rest and immobilization of both affected area and child
3. Hot, moist compresses to area

Teaching
1. Continue antibiotics for full length of treatment.
2. Use warm compresses as needed.
3. Contact dr. if pain, swelling, or increased temp occur!
4. 48 hrs- marked improvement should be seen.
Warts: Verruca?
1. Usually well-circumscribed, gray or brown, elevated, firm papules with a roughened, finely papillomatous texture
2. Occur anywhere, but usually appear on exposed areas such as fingers, hands, face, and soles
3. May be single or multiple
4. Asymptomatic

Management
1. Not uniformly successful
2. Local destructive therapy, individualized according to location, type, and number—surgical removal, electrocautery, curettage, cryotherapy (liquid nitrogen), caustic solutions (lactic acid and salicylic acid in flexible collodion, retinoic acid, salicylic acid plasters), x-ray treatment laser

1. Common in children
2. Tend to disappear spontaneously
3. Course unpredictable
4. Most destructive techniques tend to leave scars
5. Autoinoculable
6. Repeated irritation will cause to enlarge
7. Apply topical anesthetic EML.A
Verruca plantaris (plantar wart)
Located on plantar surface of feet and, because of pressure, are practically flat; may be surrounded by a collar of hyperkeratosis

Treatment
Apply caustic solution to wart, wear foam insole with hole cut to relieve pressure on wart; soak 20 minutes after 2-3 days; repeat until wart comes out

Destructive techniques tend to
leave scars, which may cause problems with walking
Herpes meds?
Herpes: Topical penciclovir
Oral antiviral: Acyclovir
Valacyclovir (valtrex): recurrent genital herpes
Herpes simplex virus Type 1 (cold sore, fever blister) Type 2 (genital)
1.Grouped, burning, and itching vesicles on inflammatory base, usually on or near mucocutaneous junctions (lips, nose, genitalia, buttocks)
2. Vesicles dry, forming a crust, followed by exfoliation and spontaneous healing in 8-10 days
3. May be accompanied by regional lymphadenopathy

Treatment
1. Avoidance of secondary infection 2. Burow solution compresses during weeping stages
3. Topical therapy (penciclovir) to shorten duration of cold sores
4. Oral antiviral (acyclovir) for initial infection or to reduce severity in recurrence
5. Valacyclovir (Valtrex), an oral antiviral, used for episodic treatment of recurrent genital herpes; reduces pain, stops viral shedding, and has a more convenient administration schedule than acyclovir

1. Heal without scarring unless secondary infection
2. Type I cold sores prevented by using sunscreens protecting against ultraviolet A (UVA) and ultraviolet B (UVB) light
prevent lip blisters
3. Aggravated by corticosteroids
4. Positive psychologic effect from
treatment
5. May be fatal in children with depressed immunity
Mulluscum Contagiosum: contact precautions?
**Put on contact isolation, it is contagious.
Molluscum contagiosum: umbilicated papules
1. Flesh-colored papules with a central caseous plug (umbilicated)
2. Usually asymptomatic

Treatment
1. Cases in well children resolve spontaneously in about 18 months
2. Treatment reserved for troublesome cases
3. Apply topical anesthetic EMLA and remove
with curette
4. Use tretinoin gel 0.01% or cantharidin (Cantharone) liquid*
5. Curettage or cryotherapy

Comments:
1. Common in school-age childrin 2. Spread by skin-to-skin contact.
including autoinoculation fomite-to-skin contact
Good Skin care plan:
1. Keep affected area clean
2. Promote good nutrition/hydration
3. Apply topical agents as indicated
4. Administer antimicrobials orally or intravenously, if needed
5. Keep it open to air as much as possible, but cover as necessary
6. Prevent further injury and secondary infection
Anti-fungal meds
Antifungals: Lotrimin & Nystatin

1. Prevention of Diaper Rash important
2. Any "tinea" of any kind is a fungus.
Scabies info & nursing considerations?
Presentation:
1. Mite burrows into epidermis
2. Often see linear lesion, grayish burrows 1 to 10 cm long ending in a pinpoint vesicle, papule, or nodule.
3. Black dot at end
4. Pruritus: INTENSE!! 30 – 60 days after contact unless previous episode
5. Typically found in webs of fingers, body creases, axilla, waistline, and near genitalia.

Treatment
1. Apply scabicial lotion to cool, dry skin over entire body from chin down.
2. Leave on for 8-12 hrs before washing off.
3. All family members and close contacts (playmates and caregivers) should be treated.
4. clothing, bedding, towels should be changed daily and washed in hot water dried in hot dryer.
5. Treat with Permethrin 5% cream (Elimite) ***APPLY LOTION TO COOL, DRY SKIN 30 MIN AFTER BATHING Leave on for 8-12 hrs before washing off.

Teaching
1. Not all lesions clear immediately and, along with itching, may persist 2-3 wks until epidermis is replaced.
2. All persons in house-hold should be treated.
3. Children should NOT share clothes, towels or hygiene items.
Lice nursing considerations?
Pediculosis Capitis
Parasite: Blood sucking organism
Needs host to survive
Female lays eggs at night
Nits: eggs hatch in 7 – 10 days
Symptom: Itching

Treatment: Permethrin 1% cream rinse (Nix)
Nit comb
Clean house, wash clothes, linen, soak combs in anti-lice shampoo or lysol diluted with water, plastic bag items for 14 days (to make sure nits are dead).

*spreads on direct to direct contact (sharing hats, combs, towels, etc)
Rocky Mountain Spotted Fever?
1. May have gradual or abrupt onset
2. Tick acquired disease (most often from rodents or dogs)
3. Maculopapular rash on extremities (ankles and wrists), but may spread to other areas, esp. on the palms and soles.
4. Ask if they have "been camping outside the area in the woods?"

Tetracyline (antibiotics) and supportive treatment

Prevention important
Light colored clothing,
tuck pants into socks,
tick checks,
Deet repellents
Lyme disease.. nursing considerations?
1. Acquired from a tick.
2. Ask if they have "been camping outside the area in the woods?"
3. Looks CIRCULAR like a "bulls eye!"

Diagnosis
1. Perform a blood test 4-6 weeks after a bite to detect the presence of the disease (testing before this time is not reliable).

Treatment
1. Amoxicillin if younger child, Doxycyline if older
2. LYMErix: 3 doses


Prevention important:
Light colored clothing, tuck pants into socks, tick checks, Deet repellents
Bites.. Nursing considerations?
1. If spider bite– what kind of spider (brown, black, hairy), where was this person?
2. Poisionous– need anti-venom.
3. When did it happen? – Want to see how it is progressing.

Treatment
Arthropods
1. Remove stinger, if applicable
2. Clean, disinfect
3. Cool compresses
4. Relieve pain, if necessary
5. Administer steroids for swelling

Mammals (human being, dog, cat, etc).
1. CLEAN IT-WELL!!!! *deep flush, let water run on it.
2. Antibiotics
3. Surgical management, as necessary
4. Immunizations, if necessary
Animal Prevention
• Teach children to avoid all strange animals, especially wild, sick, injured ones, who may be carriers of rabies (use the same techniques employed in teaching children not to talk to strangers).
• Teach children to avoid dangerous and nervous animals in the neighborhood.
• Vaccinate your own dog against rabies.
• Never permit children to break up an animal fight, even when own pet is involved. Use a rake, broom, or garden hose to separate animals.
• Teach children the danger of mistreating or teasing pets (animals bite if mauled, annoyed, or frightened).
• Spay or neuter your pets (spaying or neutering reduces aggression, not protectiveness).
• Avoid direct eye contact with a threatening dog, and remain motionless until a threatening dog leaves the area.
• Never hold your face close to an animal.
• Teach children not to disturb an animal that is eating; sleeping; caring for young puppies, kittens, etc.
• Never tease; pull the tail; or take away food, a bone, or a toy with which an animal is playing.
• Never approach a strange dog that is confined or restrained; do keep animals confined with short ropes or chains (this can make them aggressive or vicious, especially when teased).
• Do not run, ride a bicycle, or skate in front of a dog (it will startle dog); teach children the importance of avoiding bike routes where dogs are known to chase vehicles.
• Do not allow an inexperienced child or adult to feed a dog (if the person pulls back when the animal moves to take the food, this frighten and startle the animal).
• If a dog is asleep or unaware of your presence, or has not seen approach, speak to the animal to make it aware of your presence avoid startling the animal.
• Allow a dog to see and sniff a child before the child attempts to the animal.
• Do not permit a child to lead a large dog.
• Train or socialize a dog for appropriate behavior; avoid aggressive play with pets.
• Do not adopt pets for children until children demonstrate their maturity and ability to handle and care for pets.
What are the 4 types of dermatitis?
Diaper
Atopic (Eczema)
Seborrheic (Cradle Cap)
Acne
Diaper dematitis?
**Breakdown on butt should be confined to labia & cheeks.
**Trademark of candida travels up the thighs!
**Treat with anti-fungals.

Treatment w/o prescription
1. Change wet diaper and expose skin to air to facilitate drying.
2. Get super absorbent diapers.
Atopic (Eczema) treatment?
Treatment: Not a lot of chemicals– good water-based lotion.

1. Reduce pruritus (give nighttime bath, followed by lotion application and dressing in soft cotton PJs) ** Tepid water w/o harsh & perfumed soaps!
2. Avoiding exposure to skin irritants
3. Avoid over-heating (use cool wet compresses )
4. Give meds such as antihistamines, steroids.
5. Apply corticosteroid cream with a THIN LAYER rub it into the area thoroughly.

*assess for family HX. of asthma!
*scarring not likely if itching is avoided.
Seborrheic (Cradle Cap)? treatment?
1. Impetigo– funny color.
2. Sebacious glands can get this thick crust.
3. Scrape it off gently- use oil & soap.
It is not contagious, infectious, or anything.
Tinea capitis treatment
1. oral griseofulvin
2. oral ketoconazole for difficult cases
3. selenium sulfide shampoos
4. topical antifungal agents (clotrimazole, haloprogin, micronazole).
Tinea corporis (ring-worm) treatment
1. oral griseofulvin
2. antifungal preps such as tolnatate, haloprogin, miconazole, clotrimazole
Tinea cruis (jock itch)
1. local application of tolnaftate liquid
2. wet compresses or sitz baths
Tinea pedia (athlete's foot)
1. oral rigseofulvin
2. tolnaftate liquid and antifingual powder containing tolnaftate
3. acute infections- compresses or saks followed by application of glucocorticoid cream.
3. Eliminate conditions of heat and sweat by clean, light socks and well-ventilated shoes; avoidance of occlusive shoes.
Candidiasis (diaper rash.. diaper dermatitis)
1. Amphotericin B, nystatin ointment
2. Non-treatment-- let skin air and dry out
3. Put super absorbing diapers on infant.
How should the penis look after surgery?
Swollen and pink is normal-- even mis-shapen. Dusky blue is NOT normal... may indicate prob with circulation.
Urine labs?
Gravity- 1.002-1.030
pH- 4.6-8
WBC- 1-2 cells/mL (normal)
urine output- 1-2 ml/kg/hr
CSF OUTPUT- 1 ml/kg/hr
Nephrotic syndrome causes?
unknown. Lupus, diabetes, allergic response, glomerulonephritis.