PNC140 PEDIATRICS

Conserve infant’s energy

Position on side with head supported in alignment for open airway

No routine suctioning: Increases risk for bronchospasm and airway damage

• What is the treatment for RSV?

IV fluids, oxygen tent, high humidity, bronchodilators, respiratory isolation

Ribavirin: Antiviral given by inhalation; can affect eyes and reproduction of healthcare worker

• What is SIDS and who is most at risk?

Sudden unexpected death of a healthy child under 1 year old

Death occurs during sleep with no outcry or distress

½ during day, ½ during night

Greatest Risk

Low birth weight infants

Babies born to mothers under age 20

Infants not first born

Infants whose mothers smoked

Occurs more often in winter

Children 2-4 months old peak age

Baby sleeping on back has decreased incidence, also no blankets, pillows, pads, ect

GASTROINTESTINAL

• What is the treatment for Hirschsprung’s disease? What do we do to prepare the child for surgery?

Two-stage Surgery: Temporary colostomy first to relieve obstruction; second stage in 3-6 months—excise affected segment and pull normal bowel down through anus

Complete repair without colostomy in first few weeks of life

May require TPN prior to OR for malnutrition; NPO with NG to suction

Prognosis good: Need to drink more fluids due to loss of large intestine, diaper rash

Gastric pacemaker which causes GI motility

• What are some signs and symptoms of dehydration? What foods should be given/avoided?

Dry skin/mucous membranes

Depressed fontanels in infants

Increased temperature and HR and RR

Eyes sunken

BP low

Lethargic

Leads to metabolic acidosis: excess bicarbonate is lost, ketoacids are produced

Treatment

Restore fluid and electrolytes, treat cause

Oral rehydration first: Pedialyte for first 4-6 hrs in small amounts

Clear liquids until diarrhea decreased, then begin formula/breast milk

Modified BRAT diet: Bananas, rice, applesauce, toast, dry cereal, crackers, pretzels, vegetable juices (no milk products at first))

Weight: weigh diapers, I&O

Skin integrity

Teaching good handwashing to prevent infections

• Compare and contrast the GI disorders like esophageal atresia, pyloric stenosis, intussusceptions, hirschsprungs looking at causes, signs and symptoms and treatments

Too lazy to list these all out!

• What are the symptoms of Celiac disease?

Diarrhea, weight loss, anemia, loss of bone density (low calcium)

Itchy, blistery rash

Damage to dental enamel

Headaches, fatigue, joint pain, reduced functioning of spleen

Nervous system injury: Numbness/tingling of feet/hands; decreased calcium

Acid reflux/heartburn

Infant S/S : Chronic diarrhea (stools bulky, greasy, foul odor, appearance of fat); swollen belly, FTT, malnourished, short stature

GU DISORDERS

• What is a Wilm’s tumor and where is it located? What is the treatment? What should not be done with these infants once a diagnosis is made?

Most frequent intra-abdominal tumor of childhood

Malignant tumor of kidney, more common in left kidney

Peak age is 3 years old; may be hereditary and associated with other genitourinary anomalies

Signs and Symptoms

Abdominal mass (encapsulated)

Firm, nontender: once noted, abdominal palpation should be avoided so that the cells don’t break loose and spread tumor

Often found during bath

Diagnostic Tests

CT scan

Chest x-ray to determine metastasis (lung most common site)

Treatment

Surgery—nephrectomy to remove kidney

Chemotherapy with or without radiation

Prognosis

Highest survival rate of all childhood cancers

• What are the signs and symptoms of hypospadius? What is the treatment and nursing considerations post op? What is the difference between hypospadius and epispadius?

Urethra opening is located below the glans penis or anywhere along the ventral surface (underside) of the penile shaft

Signs and Symptoms

Opening other than tip of penis

Downward curve of penis called chordee: cordlike anomaly that extends the from the scrotum to the penis pulling the penis downward in an arc shape

Hooded appearance of penis because only top half is covered by foreskin

Abnormal spraying during urination

Treatment

Surgery: use foreskin for repair, usually done at 3-18 months

Stent while healing of new meatus occurs; in place for 7-21 days

Tip of stent will be visible

Encourage fluids to maintain patency of stent and hydration levels

Avoid tub baths until stent is removed; if no stent in place, tub baths avoided for 7 days

Apply bacitracin to area being careful not to block stent

Complications

Blood in urine: pink-tinged for few days is normal

Fever 102 or greater

Penis tip blue or grey or bandage seems too tight

Child unable to urinate: may urinate around and through stent

Pain not controlled by medication: may be given Tylenol with codeine which can lead to constipation

Surgery allows child to void standing with straight stream; corrects physical appearance to reduce psychological trauma

• What age group is most likely to suffer from cryptorchidism? What is the treatment?

Failure of one or both testes to descend normally through the inguinal canal into the scrotum

Incidence increases with prematurity

Factors

Deficiency of gonadotropic hormone

Mechanical obstruction

Defective testes.

Diagnosis

Physical exam

Cremasteric reflex: Stimulated by cold/touch/pain/fear, testes retract into inguinal canal; 80% of boys 1-11 the reflex can cause fully descended testes to disappear from scrotal sac; if can be moved back down, no treatment necessary; usually gone by puberty

Treatment

Medical: May observe for 6 months to year; if remain undescended, could affect fertility, tumor development, emotional issues, increased risk for torsion

Administer HCG (Human Chorionic Gonadotropin) to promote normal descent of testes; usually done with older children, less effective

Surgery: Orchiopexy, testes brought down and sutured into place; usually done at 9-15 months old; one incision in groin, one on scrotum; may use button to hold testicle down

Goal is to prevent testicular damage and malignancy

• What is Bladder Exstrophy? How is this treated?

Birth defect in which the bladder is inside out and sticks out of the abdominal wall

Other anomalies: widened pubic bone, abnormally shaped/weakened abdominal muscles, shorter than average urethra

Diagnosis: Fetal ultrasound

Treatment: Surgery, usually 24-48hrs after birth

Nursing Care

Protect bladder from infection

Cover with non-adhering plastic wrap, wet and dry dressings could dry out and stick to tissues and cause damage

MUSCULOSKELETAL

• What are the signs and symptoms of osteogenesis imperfecta?

Short stature, head normal size so looks big

Laxity in ligaments, hyperextensibility

Structural abnormalities of bone with multiple fractures

Increased bruising due to defective collagen in blood vessels

Whites of eyes may be blue, purple, gray or white

Teeth may be discolored, fragile

Smooth, thin skin

Excess diaphoresis, difficulty tolerating high temps, higher than normal body temp.

Anterior fontanel enlarged with delayed closure: may be open until 3 or 4

Hearing loss due to fracture or deformity of bones in ears

Frequent nose bleeds

May fracture due to sneeze, standing on tip toes, even turning page in a book

Above average intelligence possible

• What are the signs and symptoms of scoliosis? What is the treatment? What are some of the teaching aspects in care of this patient?

Signs and Symptoms

Uneven hips, uneven waist

One scapula or breast may appear more prominent

Forward bend, one side more prominent

Shoulder blades uneven

One arm may appear higher

Uneven pants/hemlines

Screenings may be done in schools in 5^th and 8^th or 9^th grade

Treatment

Exercise: Won’t change the curve, but still good to do

Bracing: Won’t cure, but can slow progression

Milwaukee Brace: neck ring with rests for chin; used for kyphosis

TLSO (Thoracic Lumbar Sacral Orthosis): more common, fits under arms and around rib cage; customized fit; worn until spine matures. Worn 23 hours/day: allowed to remove to bath; no lotions/powders because they can cause irritation; must wear shirt underneath

Surgery:

Harrington Rod: one rod attached to spine at two points

TSRH: 2 rods attached to spine with hooks

Post Op Care

ICU for 24 hours

Foley for 3 days

IV fluids 3-5 days

PCA for pain control

Hemovac at surgery site

O2 with pulse ox

Log roll every 2 hours

Up to chair day after surgery; early ambulation

Check skin integrity

May be emotional, anxious, often adolescent girl

• What type of infant is most likely to suffer from congenital hip? What are the signs and symptoms?

Dislocation of the head of the femur either partially (subluxation) or completely displaced from acetabulum

Risk Factors

More common in girls

First born; possible genetic factor

High levels of estrogen from mother may relax ligaments

Left leg most often affected

Children in colder climates: swaddling can put legs in adducted position

Breech position, large infant, twins

• S/S

Increased gluteal folds on affected side

Decreased abduction on affected side: lay baby on back with hips/knees flexed, press legs back until almost touches exam table (normal); affected side won’t be able to go back as far

Shortening of limb on affected side

Positive Ortolani Click: feel and hear femoral head slip

Barlow’s Maneuver: adduct hip and push thigh backward; if hip dislocates easily = positive sign

When infant prone, one hip is higher

Ultrasound of hip

• What are the signs and symptoms of Duchene muscular dystrophy? How is this disordered passed?

Progressive X-linked recessive disorder characterized by gradually progressing skeletal muscle wasting and weakness

Most common form is Duchenne’s MD

Some kinds affect only males

Large calf muscles: eventually muscle replaced by fat/connective tissue; weak, thin thighs

Protruding belly: shoulders and arms held back to maintain balance; waddling gait

Difficulty running, riding bike, climbing stairs

Clumsy, can have frequent falls

Difficulty rising from sitting to standing

Gower’s sign: Stands up with hands pushing on knees

Contractures, joint deformities

NEURO

• What is hydrocephalus? What are the signs and symptoms?

Excess of fluid in cranial vault, subarachnoid space, or ventricles

Caused by imbalance between the production and absorption of CSF within the ventricular system

Overproduction of CSF by choroid plexus: Tumors

Obstruction within the ventricular system: Tumors, infections, trauma

Defective reabsorption: Hemorrhage into subarachnoid space that blocks absorption

May develop from infancy to adulthood

If it occurs before fusion of the cranial sutures, the skull becomes markedly enlarged; if suture line close, increase ICP

Signs and Symptoms

Bulging fontanels

Separation of cranial sutures

Dilation of scalp veins

Thin and shiny scalp

Increased head circumference

“Bossing” or prominence of forehead

“Setting sun eyes” or sclera seen above iris

High-pitched cry, irritability, vomiting (signs of increased ICP)

Difficulty sucking and feeding

• What is a VP shunt? What are the signs and symptoms of shunt malfunctioning?

VP Shunt (Ventriculoperitoneal): Most common; catheter placed between lateral ventricles in brain that drains into peritoneum; notify doctor if change in level of consciousness—shunt may not be working

• What are the signs and symptoms of lead poisoning? Who is most likely to suffer from this?

Ingesting or inhaling lead-containing substances: paint chips, water from lead pipes, soil or dust contamination, folk remedies, fishing weights

Lead is deposited into soft tissues of body and bone

Attaches itself to RBCs and interferes with production of heme and formation of hemoglobin

Results in anemia; lead is stored in bones

Can alter vascular permeability and lead to increased ICP

Young children at most risk because they do not know what they should and should not put in their mouth/eat

Signs and Symptoms

Hematologic, anemia

Urine/Renal: Positive for glucose, protein, ketones

GI: may have PICA, acute, crampy abdominal pain, vomiting, constipation

Musculoskeletal: Short stature, lead lines in xray

Neurologic: mild—behavioral changes like irritability, hyperactivity, aggressive, learning problems, developmental delays; lethargic/difficult to awaken

Severe, chronic: seizures, mental retardation, increased ICP, paralysis, sensory issues, coma, death

• What is Reye’s syndrome? What may cause it? What should the nurse monitor for?

Follows a viral illness (influenza, chicken pox)

5-7 days later starts to continuously vomit, becomes drowsy, irritable, disoriented, hostile

Abnormal accumulation of fat in liver and other organs along with increased pressure in brain

Uncontrolled brain swelling is a real danger, liver damage usually reversible

Disease affects all organs but most dangerous to liver and brain

Risk Factors

Ages 5-15

Most common in January, February, March

Use of aspirin during a viral illness; do not give to children under 19

Not contagious

Mortality rate has declined

Treatment

Accurate I&O: control cerebral edema

Osmotic diuretic to decrease cerebral edema

Monitor BS, low mbs can lead to seizures

Monitor PT: prolonged PT indicative of coagulation problems as a result of liver dysfunction

Watch for signs of increased ICP!!

• What are the types of spina bifida? How do they differ? What is the treatment?

Spina Bifida Occulta:

• Most mild form

Usually no signs or symptoms; usually no visible defect

Possible S/S: abnormal tuft of hair, collection of fat, small dimple or birthmark, may only be discovered on x-ray

Meningocele:

Meninges push out through opening in vertebrae; creates cyst-like pouch; no spinal cord involvement; no nerve damage, normal spinal cord; can be transluminated (light shined on area will show up); cyst can be removed with little damage

Myelomeningocele:

Spinal canal remains open along several vertebrae

Both meninges and spinal cord protrude through opening, forming sac on back

Tissues and nerves exposed, prone to infections

Can’t be transluminated (too dense for light to shine through)

Signs and Symptoms

Depends on where opening on spine is

Paralysis is common, spine curvatures, leg, foot, hip deformities

Tethered spinal cord: cord is attached to surrounding tissues and cannot move freely

Bowel and bladder function: inability to voluntarily relax muscles that hold urine and stool; UTIs common

Seizures

Hydrocephalus

Short stature: growth hormone deficiency

Learning disabilities

Latex allergy: exposure to much latex early in life

Treatment

Surgery within first 48 hours of life; or prenatal surgery; can minimize risk of infection and protect spinal cord from trauma; closing opening and covering cord with muscles and skin

Pre-Op Care

#1 priority is to inspect anterior fontanel for bulging which may show increased ICP; would lead to shunting

Prevent infection: monitor VS, give antibiotics

Maintain stable temperature: isolette

Sterile gauze with warm saline to sac to prevent drying: do not allow sac to dry out, handle carefully; change dressing every 2 hours

Frequent checks of sac for abrasions, leaks, irritation, infection

Position on side to decrease tension on sac

Keep prone for feeding:

Diapering avoided:

Bowel sphincter affected: stool may drain continually; keep skin clean, protect sac from urine/feces, place a protective barrier

Watch for skin breakdown

Post-Op Care

Vital signs

I&O

Observe for infection, assess motor and sensory function

Keep prone for 10-14 days until incision healed

• What is cerebral palsy?

Group of disorders that affect ability to move and maintain balance and posture;

Nonprogressive

Damage to part of brain that controls muscle tone

Irreversible

Prenatal Causes: Anything that interferes with oxygen to brain, maternal infection, nutritional deficiencies that affect brain growth, drugs, radiation

Perinatal causes: Anoxia immediately before, during, after birth; maternal analgesia, birth trauma, prematurity

Postnatal Causes: Head trauma, infection, CVA

Classifications

Spastic: Increased muscle tone, muscles stiff, movements awkward; 70-80% have this

Athetoid or Dyskinetic: Slow, writhing movements they cannot control, usually hands, arms, feet, legs; may affect face and tongue and cause difficulty talking; 10-20% have this

Ataxic: Problems with balance and depth perception; unsteady when they walk; hard time with quick movements or writing

Mixed: Some have more than one kind; often spasticity and athetoid

SENSES/SKIN

• What is Otitis Media? Why do small children have more cases than adults?

Infection in middle ear often following URI

Young children’s Eustachian tube is more horizontal and wider

• What is a myringotomy? What instructions should be given following a myringotomy?

Myringotomy: Opening in eardrum to draw out fluid

Myringotomy with Tympanostomy: Insertion of tubes in eardrum

Small amount of reddish drainage normal for first few days

Report heavier bleeding or bleeding after 3 days post-op

Child should not blow nose for 7-10 days

Report any fever or increase in pain

Earplugs for swimming, baths, showers; no diving

• What is periorbital cellulitis? What is the treatment?

Serious inflammation of eyelid and periorbital area; usually unilateral and has potential to affect the eye and CNS

Causes : Conjunctivitis, impetigo, insect bites, trauma

Signs and Symptoms

Pain, tenderness

Fever, magenta-colored erythema

Edema of eyelid and periorbital area

Headache, purulent discharge

Treatment : Admitted to hospital, IV antibiotics, warm compresses, analgesics, antipyretics

• What is done for diaper dermatitis?

Keep diaper area clean and dry

Change diaper frequently

Mild soap and water—use products for sensitive skin

Leave open to air

Do not use commercial baby wipes

Use (plastic) diaper covers only when necessary: hold moisture in

• What does Candidiasis look like? How is this treated?

Thrush” common disorder in infants under 6 months; transmitted by contaminated pacifier, hands; can occur after antibiotic therapy

Caused by candida albicans

Signs and Symptoms

White patches on moist tissues: tongue, mouth, GI tract

Can look like formula that cannot be removed in mouth

On skin: inflamed pustules with whitish yellow or whitish grey patches

Treatment :

Nystatin after feedings for full 7 days, nystatin cream

Sterilize bottles, pacifiers to prevent re-infection

Risk for dehydration