Pediatric Test 2

Cardiac Topics

Cyanotic Heart Defect SpironolactoneAcyanotic Heart Defect DigoxinVSD Cardiac CatheterizationTetrology of Fallot Cardiac Patient TeachingCongestive Heart Failure Medication for Heart TransplantPulmonary Artery Hypertension Ineffective Endocarditis Rheumatic Fever

- Cyanotic Heart Defect: defects that cause decreased pulmonary blood flowo Defect that obstructs the pulmonary blood flow to the lungs or any

embryologic failure that permits no connection of the right sided blood flow to the lungs decrease pulmonary blood flow. This results in little or no blood reaching the lungs to get oxygenated.

o If an atrial or ventricular septal opening exists between the left and right side of the heart, right sided pressures exceed those on the left, resulting in RIGH LEFT shunting. Evidence of cyanosis is a classic sign of decreased pulmonary blood flow.

o The kidneys produce the erythropoietin hormone that stimulates the bone marrow to produce more RBC (Polycythemia) this can lead to thrombosis

o Signs and Symptoms: Cyanosis and CHF May have seizures due to hypoxia; fainting; confusion Marked exercise intolerance (SQUATTING helps to decrease

respiratory distress) Small stature FTT Difficulty eating Tachycardia Dyspnea Hypotonia Clubbing Frequent UTI Faint pulses Murmur

o Tetrology of Fallot Definition: a heart defect that decreases pulmonary blood flow.

There is an elevated pressure in the right side of the heart causing RIGHT LEFT shunt of blood. It is a combination of four defects:

Pulmonic stenosis Right ventricular hypertrophy

Ventricular septal Defect (VSD) Overriding of the aorta

Diagnostic: A chest radiograph shows the boot shape heart due to the

large right ventricular, decreased pulmonary vascular markings, and a prominent aorta.

ECG shows right ventricular hypertrophy Clinical Therapy:

Knee-chest position Managemen of hypercyanotic epidsodes includes placing

the infant in this position Calming the child Giving oxygen Administer MORPHINE and PROPANOLOL through IV Repair is often performed before 6 months of age when the

infant has a hypercyanotic episode

- Acyanotic Heart Defect: congenital heart defects that increase pulmonary blood flow

o The most common congenital heart defect that results from a connection between the left and right side of the heart and allows blood to flow from LEFT RIGHT and increases the amount of blood that needs to be pumped to the lungs.

o As the lungs attempt to accommodate the increased pulmonary blood flow, the infant’s heart rate and respiratory rate are increased

o Signs and Symptoms: CHF Dyspnea Tachypnea Intercostals retractions Periorbital edema

o Ventricular Septal Ductus (VSD): an opening in the ventricular septum results in increased pulmonary blood flow. Blood is shunted from the left ventricle straight into the pulmonary artery

Signs and Symptoms: Tachypnea Dyspnea Poor growth Reduced fluid intake CHF Increased upper respiratory infections Pulmonary HTN

Treatment: Surgery, however most small VSDs close with in 6 months

- Congestive Heart Failureo Definition: a disorder of circulation in which cardiac output is inadequate

to support the body’s circulatory and metabolic needs. The most common causes of CHF in infants are heart chamber and vessel pressures as well as blood volume overloads associated with congenital heart defects.

o Some defects allow blood to flow from the left side of the heart to the right so that extra blood must be pumped to the pulmonary system rather than through the aorta when the left ventricle contracts.

This overloads the pulmonary system and can lead to pulmonary hypertension

Vasoconstriction in pulmonary capillary bed right ventricle has to work harder to pump into the lungs

o Hypertrophy of right sideo Engorged liver (full of fluid)o JVD

o Obstructive congenital defects restrict the flow of blood so the heart hypertrophies to work harder to force blood through these structures.

This increases cardiac output initially, but eventually the hypertrophied muscle becomes ineffective

Failure eventually becomes bilateral o As a result organs do not receive adequate oxygenation. Blood pressure

becomes decreased and blood now supplies only the vital organs. This tells the body that to pull all blood flow from the lower extremities to supply the vital organs. As a result, there is a decrease in circulatory flow which tells the body to start that Renin Angiotensin Syndrome (retention of Na and H2O)

o Clinical Manifestations: Impaired Manifestations:

TACHYCARDIA Gallop Rhythm Diaphoresis Poor Perfusion

Pulmonary Congestion: Tachypnea Mild cyanosis Dyspnea Pulmonary Edema

o Orthopneao Wheezingo Cough

Hoarsness Gasping and Grunting Developmental Delays

Systemic Venous Congestion:

Hepatomegaly o Enlarged Liver

Edemao Weight Gaino Asciteso Pleural Effusiono Distended Neck and Peripheral Veins

o Assessment: Early Signs:

TACHYCARDIA Tachypnea Profuse scalp sweating (Infants) Fatigue Irritability Sudden weight gain Resp. distress

In Infants: CHF can be subtle Good assessment skills are a must Tires easily, especially during feedings Initial weight loss Diaphoresis, irritability, frequent infection

In Children: Exercise intolerance Dyspnea Abdominal pain or distention Peripheral edema

Assessment of Progressive disease: TACHYCARDIA Tachypnea Pallor or cyanosis Cough Crackles FV overload Periorbital and facial edema JVD Hepatomegaly Ascites Increased weight gain Bounding pulses Edema of dependent body parts

o Nursing Interventions: Decrease cardiac demands Reduce resp. distress support child and family

o Therapeutic Management of CHF: Improve Cardiac Function:

Digoxin Ace Inhibitors

o Catopril o Enalapril

Remove accumulated fluid and sodium Lasix

Decrease cardiac demands Improve tissue oxygenation

o Medication Therapy: Positive inotropic effect and afterload reducing agents

Digitalis o Digoxin:

Administer it everyday at the same time with or w/o food

Check apical pulse for full minute to note bradycardia

Check potassium levels if diuretics are loosed

Low K can increase the effects of digoxin

Observe for toxicity Tachycardia

o Young children Bradycardia

o Older children N/V Anorexia Dizziness Headache Weakness Fatigue Arrhythmia

Therapeutic Levels: 1.1 – 1.7 ng/mL

o ACE inhibitors (Angiotensin converting ezyme inhibitors)

Lisinoprilo Beta Blockers:

Indural (propanolol)o Diuretics:

Lasix HCThiazide

Aldactone (Spironolactone) Potassium sparing

o Supportive Treatment: Oxygen Fluids as indicated (cautious in CHF patients) Increased calories or concentrated formula Airway support/management Rest and spacing of activity/rest periods

o Surgical Treatment: Cardiac Catheterization:

An outpatient procedure Assessment Preoperatively

o Childs vital signs o Hematocrit and hemoglobino Capillary refillo Skin temperatureo Strength of the pedal and popliteal pulse

Ensures comparison for pre and post surgical intervention

Assessment Postoperatively:o Monitor the child for potential complications such

as: Arrhythmia Bleeding Hematoma development Thrombus formation Infection

No bleeding should occur at the cath site Vital Signs are done Q 15 minutes for 1 hours includes:

o Perfusion of the lower extremities: Pedal and popliteal pulses Skin temp Color Capillary refill Sensation

o Pressure dressing Monitor I/O because dye may cause diuresis Ileofemoral aretery injury is more common in newborns

and young infants after catheterization

- Medication for Heart Transplant o Triple immunosuppression regimen:

Tacrolimus or Cyclosporin A Azathioprine

Corticosteroids High doses of IV steroids are used to treat episodes of acute

rejection

- Pulmonary Artery Hypertension:o An increase pulmonary blood flow, pulmonary vascular resistance

develops. The pulmonary vascular bed compensates to reduce this excessive pulmonary blood flow by vasoconstricting. This leads to right to left shunting of blood (cyanotic)

o Clinical Manifestations: Hypoxemia Acidosis Tachypnea Cyanosis Retractions Fatigue Difficult feeding Weight loss F&E imbalance Older children:

Exertional dyspnea Chest pain Syncope

o Collaborative Care: Surgery to correct an obstructive lesion or close a defect Noncardiac conditions involves:

Bronchodilators Antibiotics Corticosteroids Low flow oxygen

Short term nitric oxide therapyo Nursing Management:

Promoting rest for oxygen conservation Monitoring I/O Administering medication and oxygenation Exercise should be tailored to avoid dyspnea Give parents needed support and information about their child

- Inefective Endocarditis:o An inflammation of the lining, valves, and arterial vessels of the heart

caused by bacterial, enterococci, and fungal infections. o Infection may occur due to:

Invasion of organism into the bloodstream during dental work or surgery and lodges on damaged or abnormal endocardial tissue.

Children with congenital heart disease, a high velocity or turbulent blood flow can injure the endocardium.

Indwelling catheters positioned in the right side of the heart also damage the endocardium or valve endothelium

o Clinical Manifestations: Prolonged low grade fever Fatigue Weakness Weight loss Joint and muscle aches Diaphoresis New or changing murmur CHF Decreased oxygenation saturation level Dyspnea Hematuria Petechiae Splenomegaly Children w/ indwelling catheters may initially have pulmonary

symptoms or signs related to septic pulmonary embolism Newborns have variable nonspecific signs such as:

Feeding difficulties Respiratory distress Tachycardia

o Diagnostic Procedures: The Duke Criteria

o Clinical Therapy: Administering antibiotics by way of IV for 2-8 weeks:

Penicillin G Ampicillin Vancomycin Nafcillin Gentamicin

Surgery to replace a valve o Nursing Interventions:

Respiratory and Cardiovascular status Vital signs Oxygen saturation LOC as congestive heart failure and embolism may occur Child will be placed on a cardiac monitor and pulse oximeter Teach parents to ask for prophylaxis specifically prior to

procedures: Tonsillectomy or adenoidectomy Bronchoscopy Surgery on the respiratory, GI, and GU systems

Children at moderate to sever risk for ineffective endocarditis should restrain fro

Body piercing

o Noseo Tongueo nipple

Tattoos Keep invasive procedures to a minimum Use careful aseptic technique in performing:

Venipunctures Urinary catheterizations

- Rheumatic Fever:o An inflammatory connective tissue disorder that follows an initial

infection by some strains of group A beta hemolytic streptococci. This disorder effects the heart, joints, brain, and skin tissues.

o Clinical Manifestations: 1 – 3 weeks after an untreated streptococcal infection, the hallmark

signs of rheumatic fever may occur. Carditis:

o Aschoff bodies (hemorrhagic bullous lesions) develop in the connective tissue of the heart. Murmurs of the mitral and aortic can be heard

Arthritis:o Childs joints become inflamed and painful. The

large joints are more commonly affected with pain, swelling, tenderness, erythema, and heat. May migrate from join – joint (polyarthritis)

Subcutaneous nodules may be palpable near joints Erythema Marginatum:

o A skin rash with pink macules and blanching in the middle of the lesions, is infrequently seen. It is seen on the trunk and proximal extremities, but not on the face.

Sydenham Chorea:o Aimless movements of the extremities and facial

grimacing. o Diagnostic Procedures:

Clinical signs Lab Testing:

Antistreptolysin-O (ASLO) titer: to detect previous streptococcal infection.

o Clinical Therapy: Antibiotics:

Penicillin Sulfadiazine Erythromycin

Aspirin

Traditional anti-inflammatory medication prescribed for 3-4 weeks, or longer if carditis is present. Serum levels are administered can cause problems

Steroids

Genitourinary Topics

Hypospadias Renal Failure

Obstructive Uropathy Drug to suppress Kidney Transplant RejectionUTI HemodialysisDrug to treat Enuresis BactrimNephrotic Syndrome PyloromyotomyGlomerulonephritis Prednisone administration

Hypospadias o urethral meatus located on the ventral surface of the penile shaft

o Diagnosticso Ultrasound (prenatally)o Physical exam (at birth)

Surgical repair (usually same day surgery)

Family teachingo Double-diapering techniqueo Activity limitationso Hydrationo Medicationo Signs of infectiono Color of urine

Obstructive Uropathy

o Structural/functional anomalies that alter normal urine outflowo Pressure caused by urine backflow can result in hydronephrosiso Physiologic changes caused by hydronephrosis Glomerular filtration stops when the pressure in the kidney pelvis =

the filtration pressure in the glomerular capillaries Metabolic acidosis (the impaired distal nephrons are unable to secrete

hydrogen ions) Kidney unable to concentrate urine Urinary stasis Restricted urinary outflow

Clinical manifestations of congenital obstructive lesionsObstruction Site Obstructive Lesion Clinical Manifestations

Infants childrenUreteropelvic valve Ureteropelvic junction

obstructionAbdominal massHypertensionUTI

HematuriaPainIntermittent N/V

Stenosis @ ureterovesicular junction

Ureterovesicular junction obstruction

UTIHematuriaPainAbdominal MassEnuresis

Posterior urethral valve

Posterior urethral valves Abdominal massDistended bladderPoor urinary streamUTIPolyuriaSepsisFailure to thriveDecreased specific gravityIncreased creatinine level

Urinary frequency Incontinence

Prevention of kidney damage and the decline of renal function are crucial!!

Surgical correction or diversion may be necessary to decrease the pressure within the urinary collecting system

Urinary Tract Infection:Clinical Manifestations and Clinical Therapy for UTI

Type of UTI Clinical Manifestations Clinical TherapyLower UTI – cystitis Frequency

DysuriaUrgencyEnuresisStrong-smelling urine

5 – 7 day course of trimethoprim or sulfamethoxazole or Antibiotic for specific organism

Encourage fluids Analgesic (Tylenol or pyridium)

Upper UTI – Pyelonephritis

High feverChillsAbdominal painFlank painPersistent vomitingModerate to severe dehydration

Rehydration Antipyretics IV antibiotics to oral antibiotics

for 7 – 10 days

Common Nursing Diagnoses for the child with UTIo Altered urinary eliminationo Risk for altered growtho Urinary retentiono Risk for ineffective management of therapeutic regimen

Risk for fluid volume deficitRenal Disorders

o Nephrotic Syndrome

Congenital Primary

Type of primary – minimal change nephritic syndrome (MCNS)

Most common form Secondary

o Acute Poststreptococcal Glomerulonephritis (APSGN) Most often a response to group A beta-hemolytic streptococcal

infection of the skin or pharynx More common in boys

APSGN vs Nephrotic SyndromeAssessment Factor APSGN Nephrotic Syndrome

EdemaHematuriaProteinuriaBlood PressureAnorexiaPain, discomfortFatigue, activity intoleranceSerum albumin/protein levelsSerum lipid levelsSerum electrolyte levelsHemoglobin and hematocritSerum creatinine and BUNSerum streptococcal antibody titersAge at onset

Nursing Intervention APSGN Nephrotic SyndromeIntake and Output

Weight Measurement

Diet

Fluids

Positioning

Skin Care

Medications

Renal FailureAcute Renal Failure (ARF) vs Chronic Renal Failure (CRF)

Types of Renal Failure Clinical Manifestations DiagnosticsARF Gross hematuria

HeadacheEdemaSevere hypertensionLethargyN/VOliguria

Urinalysis Low pH Osmolarity Specific gravity + proteinBlood Chemistry Elevated K+ Na+ varies Low Ca+ High Phosphorous BUN increased Creatinine increased Low pHo

CRF FatigueMalaisePoor appetiteProlonged,unexplained N/VFailure to thrivePoor school performanceSecondary enuresisChronic anemiaHypertensionUnusual bone disease

Serum electrolytePhosphateBUN Creatinine levelspH

- Drugs to treat Enuresis:o Desmopressin Acetate (DDAVP):

A vasopressin with an anti-diuretic effect. It reduces urine production for 8-12 hours. It may be administered by way of nasal spray or tablet. Used for enuresis

It is often given to kids for sleep overs and camping Parents should monitor Blood Pressure and Weight

o Oxybutynin (Ditropan): An anticholinergic used for enuresis that relaxes smooth muscle of

the bladder that promotes bladder tonicity (capacity). It is given in the form of oral administration and extended release tablets.

Teach parents to monitor effects. It may also cause dry mouth

o Imipramine (Tofranil): A Trycyclic Antidepressant useful in nocturnal enuresis due to

anticholinergic activity and nervous system stimulation. This helps with earl arousal.

Monitor for mood changes and excessive fatigue Administer 1 hour before bedtime and with food Weigh child 2X/weekly and monitor for edema OTC drugs are avoided

- Drugs given to suppress rejection of kidney transplant:o After transplantation, the child receives immunosuppressive medications

such as: Corticosteroids Azathiprine Cyclosporine Antilymphocyte antibodies

- Hemodialysis:o Requires creation of a vascular access and special dialysis equipmento Best suited for children who can be brought to facility 3x/week for 4-6

hourso Achieves rapid correction of fluid and electrolyte abnormalities

GI Topics

Abdominal distention Gastroesophageal RefluxPylorotomy Hirschsprung’s DiseaseTransesophageal Fistula GastroenteritisOstomy Care Appendectomy (Pain Management)Pyloric Stenosis Celiac DiseaseRotavirus

Acute Gastrointestinal Disorders: (Gastrointeritis)

Rotavirus:o Common cause of diarrhea in children

Found in the (nursery setting )o It is characterized by 2 days of fever and vomiting, followed by 5-7 days

of watery (explosive) diarrheao Most incidents occur with the child presenting to the ER with a diagnosis

of dehydration. They may also have electrolyte imbalances as well as fluid

imbalances. - Assessment of Rotavirus and Clostridium difficile (C. difficile):

o Nursing History: Assess possible exposure Onset Descriptions of symptoms and length Other events: weight loss, stool patterns, eating patterns Reports of fatigue and malaise

o Obtain baseline Height and Weight

o Nutrition: Maintain nutrition with fluids and this is determined by weights

o Signs and Symptoms of dehydration: Dry mucous membranes Poor skin turgor with paleness Tachycardia Sunken fontanels Decreased urine output and concentrated

Specific Gravity: High Thirsty Blood Pressure: decreased b/c of volume decrease Decreased potassium

- Interventions for Rotavirus and C. difficile:o Obtain stool sample

Occult blood testo Monitor I/O’s

urine and stool

o Obtain daily weightso Avoid rectal temperatures

VS q 4 hourso Administer IV fluids as ordered o MEDICATION OF CHOICE FOR C. DIFFICILE

Metronidazole (flagyl) o Education:

Handwashing Avoid

Fruit juices Carbonated beverages Gelatins

o All of these things have increased CHO, decreased electrolyte, and decreased osmolarity

Caffeineo Diuretic effect

BRAT diet is no longer used because it is not nutritious o Inform school or child care center (Rotavirus)o Monitor Labs:

Specific Gravity CBC Electrolytes Arterial Blood Gases

For diarrhea you may see Metabolic Acidosis (loss of Bicarbonate through stool)

o Implement bowel rests The first feeding after bowel rest should be cooked cereal

- Diagnoses for Rotavirus and C. Difficile:o Anxietyo Diarrheao Deficient fluid volume r/t increased peristaltic activity o Hyperthermia r/t presence of invading organismso Imbalanced nutrition: less than body requirements r/t frequent loose

watery stools and vomitingo Acute pain r/t inflammationo Impaired skin integrity

- Preparation for admission of a patient with these types of disorders:o Child will appear:

LOC: Lethargic Irritable

Lung Fields:

Should be normal if no other problems are arising Cardiac:

Increased pulse (thready) Low BP

Abdomen: Distended Increased bowel sounds r/t gastrointestinal motility Tender upon palpation Older child may verbalize cramping, hunched over, and

crying Urine:

Concentration of urine Increased urine specific gravity

Bowel Status: Watery stools Fowel smelling Color may be GREEN due to the bile Frequency increases Possibility of blood tinged stool due to inflammation

Activity level: Lethargic Clinging to parents Not interested in anything else

Nutrition: May not be able to tolerate formula, breast milk, and clear

liquidso Child may be placed on bowel rest for a few days

with administration of IV fluids. Integumentary:

Turgor:o Assess on the abdomen for babies

Diaper area must be cleaned and applied with butt paste (dry area completely before applying the butt paste)

Types of Pathophysiology Associated with Congenital Gastrointestinal Defects:

- Hirschsprung Disease: gastrointestinal defect that is also called (Mega Colon). In a normal healthy colon you have nerve cells that trigger muscles to move the stool down the intestine through the anus and out. In this disease the nerve cells somehow during development stops developing. Therefore there is no peristaltic movement and what happens the stool is pushed down and behind it comes more and causes a major backup. It requires surgery.

o Clinical Manifestations: Newborns:

Failure to pass meconium Reluctance to ingest fluids

Abdominal distention Bile stained emesis due to back up

Infants: FTT Constipation Abdominal distention Vomiting and episodic diarrhea because some stool may be

allowed to pass Older Children:

Anorexia Chronic constipation Foul smelling and ribbon like stools Abdominal distention Visible peristalsis Palpable fecal mass Growth retardation Signs of anemia Hypoprotenemia (due to disruption in absorption)

o Diagnostics: Barium Enema:

Barium is placed into the intestines and it will detect the part that is applicable to Hirschsprungs Disease with an X-ray

Rectal Biopsy: To test for the nerve cell

o Most accurate test Anorectal Manometry:

A small balloon is placed inside of the rectum and normally the anal muscle will relax once it is placed inside if it does not then it is diagnosed as Hirschsprung Disease

o Removal Technique: Remove a piece with a stoma left, so child may have colostomy

after procedure. Pull-through surgery is a type of surgery where they take the

diseased part out, and hopefully they have something to attach it to.

o Nursing Management: Promote adequate hydration

water Promote adequate nutrition

High fiber foods like bran muffins and cereal o Secondary infection in small intestines:

Interocolitis: it can happen before or after surgery for defect S/S:

o Fevero Swollen abdomen

o Vomitingo Diarrheao Bleeding from rectumo Sluggishness

o Treatment: Forceful rectal washouts to decompress the colon IV antibiotics Colostomy Monitor for perintonitis = inflammation of the lining of the

abdomen Monitor F/E Blood replacement if perfuse amounts of blood are lost

- Perotinitis:o Assessment

Absent bowel sounds Severe pain High fever Increased White blood cells Possible shock and death

o Nursing Care of Perotinitis: Pain Management IV fluid management Nasogastric tube to suction IV antibiotics

Malabsorption Disorders Definition: when a child is unable to digest or absorb nutrients in the diet

- Celiac Disease: is more of a diet based disease. A person can not eat gluten, which is a protein found in meat, rye, and barley. It may also be found in some medications. It is a hereditary disease, but hard to discover.

o Treatment: Gluten free diet Work with dietician on what foods to avoid:

Processed food:o Cold cuts, hot dogs, salami, french fries, soy sauce,

wheat products, semolina, o Clinical Manifestations:

Some times asymptomatic or just a few symptoms Gas Diarrhea Stomach pain Feeling very tired Anemia Weight loss

Change in mood Very itchy rash with blisters Slow growth

o Diagnostic: Blood test Biopsy

Pathophysiolgy of Acquired Gastrointestinal Defects:

- Pyloric Stenosis: thickening and tightening of pyloric sphincter creating an obstruction. It is common in 1st born males. It is an olive shaped mass. The thickening that occurs the hypertrophy areas it presses down on the pyloric channel causing a stricture. Stenosis occurs between stomach and duodenum (right upper quadrant). The best time to palpate this olive mass is on an empty stomach. The abdomen muscles must also be relaxed when palpating so the best time to do this is when they start to eat (sucking) and the stomach is empty at this time as well.

o Clinical Manifestations: Regurgitation or nonprojectile vomiting starts around 3 weeks of

age Then the vomiting will increase in frequency and force over the

next 1-2 weeks and becomes very projectile Weight loss, because whatever they eat it comes right back out Upper abdominal distention Palpable olive shaped mass Stools become less frequent with volume decreased Signs of malnutrition and dehydration will occur

Vomiting usually occurs 30-60 minutes after the meal You may also observe peristalsis when they are lying down

Normal peristalsis is from left to right/ theirs will be right to left making everything come up instead of down

o Diagnostic: Ultrasound and Upper GI ABG’s : will show metabolic alkalosis: Electrolytes:

Excessive loss of Potassium, Hydrogen, and Chloride KNOW VALUES of K, Na, Cl

CBC: Increase BUN indicating dehydration

o Treatment: Pylorotomy:

Procedure is done as soon as infants F/E are stabilized The overall goal of the surgery is to release the circular

muscle fibers to allow the passage of food and fluid Postoperative Care:

o Position them with the head of bed up 30 degrees to prevent reflux. But because of the peristaltic action

place them on their right side so that left to right peristaltic action will develop

oIf the emesis is present during or following the procedure it is considered the infant is unable to tolerate feedings. So start slow and small.

- Gastroesophageal Reflux: (GERD) gastric contents back up into the esophagus caused by three mechanisms. It causes gastric distention, and slows gastric emptying, hiatal hernias in the presence of gastrostomy tubes. Reflux acidity damages the esophageal mucosa and can potentially be detrimental to the respiratory system if aspirated. It can also cause periods of cyanosis. Found more often in premature babies and infants with other disorders like Cystic Fibrosis and Cerebral Palsey

o Lower esophageal relaxationso Incompetent lower esophageal sphinctero Anatomic disruption of esophagogastric junction

o Clinical Manifestations: Forceful vomiting Weight loss Aspiration Cyanotic and apneic episodes that may be life threatening

o Treatment: Medicaiton:

Omeprazole (Prilosec) a PPI which blocks the production of acid producing cells.

o Diagnostics: Upper GI Intraesophageal pH monitoring, which is placed down into the

esophagus and measures the pH as the reflux comes up. Nurse must document pH change

o May require surgery if it wraps around the fundus of the stomach but rareo This usually goes away as the child gets older and may have a revisit of

the disorder in adulthood

- Potential Signs of GI Emergencies in Infants: o Esophageal atresia and tracheoesophageal fistula (TEF) is a clinical

and surgical emergency. It is a congenital anomaly in which the esophagus is not fully developed, so I forms a blind pouch in the upper esophagus with the large part of the esophagus connected to the trachea. This is why aspirations occur. It is easily detectable when feeding.

Cyanosis Coughing characterized by 3 C’s Choking Also excessive salavation Respiratory distress and aspiratory pneumonia

Nursing Intervention: Monitor respiratory status Remove excessive secretions (usually continuous suction to

the blind pouch) Put them in an upright reflux position with the head and

shoulders elevated to assist in pulling of the secretions to the bottom of the pouch

Provide oxygen as prescribed NPO Admin IV fluids

Postoperative Intervention: NPO Admin IV fluids Monitor I/O Provide G Tube care and feedings as prescribed Because they are new born take care of their Trust vs.

Mistrust as well as Oral Phase (pacifier is needed) Monitor for postoperative stricture of the esophagus

o Post surgical complication of TEF Promote parent infant bonding

- Appendicitis: is an inflammation of the vermiform appendix, the small sac near the end of the cecum. Occurs most often in adolescent males 10-19

o Clinical Manifestations: Onset:

Periumbilical cramps Abdominal tenderness Fever

Later: Pain in right lower abdomen Guarding Rigidity N/V Onset of pain before vomiting Anorexia Rebound tenderness

o Contraindicated because it causes so much pain if palpated

Pain induced flexion of the hip (psoas sign)

Ruptured Appendix: Sudden relief of S/S Fever Abdominal distention Rapid shallow breaths Pallor

Chills Diagnostic:

CT scan is most reliable test Treatment:

Immediate surgery Child is kept NPO IV fluids Antibiotics if ruptured Nasogastric tube Penrose drain is inserted if ruptured before surgery

Nursing Intervention: Position child on side-lying position preoperatively with

knees bent Admin analgesics Postoperative place the child in semi-Fowlers or side lying

on right side to promote drainage DO NOT USE A HEATING PAD

o May induce rupturing and increase inflammation Assess fluid volume every 2 hours Postoperatively do not administer anything by mouth until

bowel sounds return and start out with small sips of water and then progress.

Assess surgical sight for signs of infection

Endocrine TopicsGrowth Hormone InjectionsDiabetes InsipidusSyndrome of Inadequate Antidiuretic HormoneHyperthyroidism

Diabetes MellitusKetoacidosis

- Growth Hormone Injections:o Used to treat Hypopituitarism, which is known as growth hormone

deficiency.o Guidelines for approved indications from the FDA:

GH deficiency/insufficiency Chronic renal insufficiency/pretransplantation Turner syndrome Short stature from Prader-Willi Syndrome (PWS) Children w/ a history of intrauterine growth restriction (small for

gestational age SGA) who have not achieved normal height by two years of age

Children with idiopathic short stature who are >2.25 SD below the mean in height and who are unlikely to catch up in height.

Adults with growth hormone deficiency Adults with AIDS wasting

o Most indications for GH replacement require daily GH injections It is being investigated for children with Cystic Fibrosis and other

disorders. o Effects:

The child will experience increased growth velocity for the first year of treatment, followed by a gradual decrease in growth for subsequent months or years.

However, growth should progress a least at the normal growth rate for age while continued on growth hormone treatment.

If it is slower than improper preparation is the reason Therapy is continued until either the child achieves an acceptable

height or growth velocity drops to less than 2cm (1 inch) per year. Child should receive close monitoring from an endocrinologist

every 3-4 months. o Side Effects:

Arthralgia Carpal Tunnel Syndrome Myalgia Reduced Insulin sensitivity Slipped capital femoral epiphysis Gynecomastia Progression of scoliosis and hypothyroidism Benign increased intracranial pressure.

o Additional SE: Mild swelling Headaches Peripheral edema

Common in children with Turner Syndrome

Lipoatrophy

- Diabetes Insipiduso Central Diabetes Insipidus (ADH Deficiency Familial or Idiopathic): there

is a deficient production of ADH Clinical Manifestations:

Polyuria Polydipsia Nocturia Enuresis Irritable if fluids with held Constipation Fever Dehydration

Clinical Therapy: Desmopressin acetate (DDAVP)

o Nephrogenic Diabetes Insipidus (Inherited or acquired responsiveness of kidneys to ADH): kidneys can not respond to ADH. It can be caused from drug toxicity from drugs such as: (lithium carbonate (Carbolith), demeclocycline (Delclomycin), amphotericin, cisplatin, foscarnet, methicillin, and rifampin.

Clinical Manifestations: Polyuria Polydipsia Hypernatremia in neonatal period Dehydration Vomiting Changes in Mental Status

Clinical Therapy: Diuretics High fluid intake Salt and protein restricted diet

- SIADH (Syndrome of Inappropriate ADH): hyper secretion of the posterior pituitary hormone ADH

o Etiology: Infection Tumors CNS disease or trauma

o S/S: Related to fluid retention and hypotonicity Dilutional hyponatremia

o Therapy: Monitor for fluid overload:

Restrict fluids Accurate I/O

Daily weight Seizure precautions Concentrated and decreased urinary output

Treatment: Diuretics Demeclocycline (Declomycin)

o Blocks ADH action Sodium supplementation

- Diabetes Mellitus

- Diabetic Ketoacidosis:o Diabetic Ketoacidosis (DKA):

This occurs in our Type I diabetics They present themselves with an elevated glucose They are hot and dry (sugar high) very dehydrated

They need to be re-hydrated with Normal Saline usually a large infusion rate

Acidosis always causes CNS depression so they their blood sugar may not be as high but they become acidotic

Treat their glucose levels with regular insulin IV infusion along with a sliding scale

Now when the blood sugar drops to 250 stop the infusion and replace fluids with D5W or D5 normal. The reason being you need to stop ahead of time before because they have the potential of bottoming out.

Their K+ is probably high (hyperkalemia) because of “ACIDOSIS” but watch because they can turn into hypokalemia because K+ hops on with insulin and glucose enters into the cell. So treat K+ situation. No need to treat hyperkalemia with Kexalate because the insulin enough will bring it down.