Peds Quiz 2 Outline - lecture notes for exam 2 PDF

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Chapter 22: Child with GI Dysfunction 

dehydration o develop quickly in infants and young children o occurs when total output of fluid exceeds the total intake regardless of cause o usually vomiting or acute viral or bacterial diarrhea can cause dehydration o mild, moderate, or severe o s/s  wt loss  lethargy  cyanosis  decreased voiding  babies sunken fontanel  dry mucous membranes  pale  BUN increased  tachycardia is earliest sign*** o assess  dry skin turgor  weights daily  urine output  LOC  #1 sign when child is in severe dehydrationcrying but don’t have any tears  sunken in fontanels for infants  cap refill is above 3 seconds o diagnostic evaluation  isotonic  level of electrolytes and water deficits are the same  hypotonic  electrolye deficit exceeds water deficit  hypertonic  water loss and excesive electrolyte loss o therapeutic management  correct fluid loss or deficit  treat underlying disease  oral rehydration manegemtn  mild: 50 ml  moderate: 100 ml  diarrhea: 10 ml/stool  vomiting o oral syringe: 2-5 ml every 2-3 mins o Zofran

o if throw up  do the same thing again o when child is vomiting  give less amount of fluid o severe drhydratin  parenteral fluid therapy  usually isotonic solutions: 0.9% NaCl lactated ringer  3 phases  IV bolus o rate 20 ml/kg over 20 mins repeat as necessary  replacements of deficits to meet maintenance and electrolyte requirements and catchup with ongoing losses  begin oral feedings  anytime kid is vomiting or diarrhea, give fluid bolus o nursing management  observe for signs of dehydration  assess VS  record and monitor weight  accurate I&O  I&O FIRST then weight  parent education  daily weights  weights will change on daily basis not in a few hours o use same scale at same time o acute diarrhea  leading cause of illness in children younger than 5 years old  will get this from not washing hands  rota virus  3 doses of rota Ted at 2, 4, and 6 months  2 doses of rotarix at 2 and 4 months  NO BRAT DIET  not enough calories in this  soft pureed foods, cooked cereals or veggies  no soda or fruit juices o therapeutic manegemtn  fluid and electrolye imbalance  rehydration therapy  oral rehydration therapy is treatment of choice for most cases  teach parents signs and symptoms of dehydration  reintroduction of an adequate diet  no brat diet  no fruit juices or soft drinks  yogurt helps

 reestablishing healthy bacteria in gut o Hirschsprung disease  mechanical obstruction  inadequate motility of the intestine due to absence of ganglion cells of colon  80% of cases due to anglionosis restricted to internal sphincter rectum and a few centimers of sigmoid colon  leads to a decreased ability of the internal sphincter to relax  decreased peristalsis  stools backs up and distends the sigmoid colon  no meconium within first few days  result of missing nerves in muscles babies colon  internal sphincter is unable to relax and let stool go  s/s  refuse to eat  abdominal distention  can have signs of entero colitis  hyperactive bowel sounds  therapeutic management  treatment is surgical  correct any fluid and electrolyte imbalances  surgery o removal of aganglionic portion of bowel o temporary ilestomy or colostomy o restore normal activity o preserve function of the external anal sphincter  nursing management  pre op o bowel evacuation  saline enemas o low fiber diet before surgery o colonic irrigations with antibiotic solution to decrease flora o ongoing abdominal measurements to assess increased girth  post op o NPO after surgery with IV therapy o most have NG tube o when bowel sounds return, clear fluids and then move to solid o whole fam needs to learn how to take care of stoma o pyloric stenosis  constriction of the pyloric sphincter with obstruction of the gastric outlet palpable olive like mass

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develops first 2-5 weeks of life hardening of the pyloric sphincter no bile in this vomit bc it’s not going anywhere except stomach**** s/s  projectile vomiting  dehydration  metabolic alkalosis  growth failure  can only be surgical  keep NPO with IV therapy  surgery is done same day as diagnosis  can start eating 12-24 hours after surgery  may still throw up a little bit after this surgery but normal  complications  infection  bleeding  management  pre op o NPO with IV therapy o correct metabolic alkalosis o daily wt  post op o assess site o monitor IV o I&O o VS o some vomiting common o when able to sart on clear fluids o advanced diet o cleft lip and palate  cleft lip  results when the maxillary and median nasal processes fail to fuse with the nasal evaulations on the frontal promence  happens around week 6  cleft palate  results when the secondary palate fail to fuse  happens between weeks 7-12 weeks of gestation  opening in pallet and opening in lip  may have one or other  people who have this is congenital and environmental o surgical management  cleft lip  repaired between 2-3 months of age

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rule of 10’s o 10 weeks of age and weigh 10-12 lbs  free of any oral, respiratory or systemic infections  two common procedures o use a z plasty incision to minimize notching of lip o upper third of lip advances a triangle of tissue o procedure chosen is individualized o often use a combo of both o may need additional revisions if very severe  cleft palate  repaired between 6-12 months  takes advantage of palatal changes with normal growth  studies show children are younger when repaired exhibit better articulation and resonance pre op for cleft lip  at risk for aspiration with feeding  when breastfeeding, close cheeks of baby so it closes hole  mom needs to help with seal  burp often  feed with head and chest elevated  special nipples and bottles post op for cleft lip  do not put anything traumatizing in baby mouth  cause trauma to suture line after surgery  sit them higher to let their secretions go  start eating when they are alert and awake  if older kid, don’t give any hard food to kid  soft diets  observe suture for infection  cleanse lip incision after feeds pre op for cleft palate  device for feeding  breastfeeding needs to be done by putting breast tissue in hole and cause suction  babies with this are at more risk of ear infection  opening in palate can fill with milk and connected to Eustachian tube which can collect with milk and cause infection o help them fight infections, encourage breast feedings  syringe feeding  before surgery, may transition to cup feeding post op for cleft palate  position to cause drainage and secretions  avoid oral suctioning, objects in mouth for 7-10 days

 don’t brush teeth for 1-2 weeks  pain relief  may do dropper feeds  breast feed  burp more often  rinse mouth with sterile water  prevent child from sucking o long term problems  speech problems and production  otologic problems  ear infections  hearing impairments  dental and orthodontic issues  developmental concerns o EA and TEF Congenital Malformations  esophagus ends before reaches stomach  a fistula is present that forms unnatural connection with trachea  cause is unkown  occurs during 4-5th week of development  cells of embryonic foregut fail to develop  creates a blind pouch (atresia)  embryonic gut fails to divide into separate trachea and esophagus  findings and diagnosis  3 C’s o coughing o choking o cyanosis  failure to pass suction cath or NG tube  excessive oral secretions  apnea  increased respiratory distress during feeding  abdominal distention with TEF  airless, scaphoid abdomen  hx of maternal polyhydramnios***  atresia suspected if suction cath can’t be passed 10-11 cm beyond gum line  abdominal x ray shows o proximal esophagus dilated with air o abdominal distention  therapeutic management  prevent aspiration and pneumonia  keep head of bed elevated  if kid is going to throw up, risk of aspiration

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maintain airway aspirate whatever is in pouch with NG suction o suction give broad spectrum antibiotics NPO with IV fluids provide oxygen staged repair o place G tube through anastomosis o dilate ends many times/day to stretch o later  anastomosis, gastric tube or colon interposition and dilation done complication o esophagus is not dilated well so food doesn’t go thrugh so start seeing choking, not able to swallow  bring child back to dilate esophagus best position o supine with elevation o inclined  put mattress a little higher or put something under mattress; no blankets**** check airway aspirate if needed make sure lung pouch is emptied via NG tube on suction

   pre op  assessment for aspiration  monitor for respiratory distress  measure abdominal girth  NPO/IV fluids  strict I&O  temp and other VS  supine position preferred but sometimes is prone  always has head of bed elevated at least 30 degrees  change tubes as needed  pacifers vs no pacifiers post op  respirations  support fluid balance  maintain thermoregulation  pain relief  monitor infection  maintain chest tube  GT is elevated initially to prevent distention

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GT for feeding until incision heals barium swallow or esophagram evaluates incision integrity

Chapter 23: Child with Cardiovascular Dysfunction  

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factors contributing to CHD o genetic and environmental, combo of genes from both parents maternal factors o seizures o ingestion of lithium for depression o lupus o german measles o drug or alcohol abuse chromosome abnormalities o downs syndrome  more than 50% of children with downs syndrome have CHD  most common is atrioventricular septal defect o Patau syndrome o Edwards syndrome o Charge syndrome o Cat eye syndrome o Digeorge syndrome o William’s syndrome diagnosis of CHD: prenatal o suspected during ultrasound scan of fetus in womb o EKG completed around 18-24 weeks o may be done if fam hx of CHD where there’s an increased risk diagnosis of CHD: postnatal o usually present immediately after birth  72-96 hours after birth so they can go home with a defect  baby is using mom’s circulation in womb so notice quickly after birth bc they’re now using their own circulation o obtain a detailed hx  listen to parents  nutritional state  respirations  taigue, exercise intolerance  changes in color such as pallor/cyanosis  hx of infections  fam hx of CHD o ductus arteriosis  when baby is born, closes soon after baby is born but not always

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diagnosis of CHD: exam o vitals and weight o detailed physical assessment  cyanosis; not always depending on defect  clubbing  hepatomegaly  splenomegaly  peripheral pulses not equal o auscultation  abnormal heart sounds  murmurs  clicks  rate and rhythm o palpation  bruits  thrills  pulses  cap refill diagnosis of CHD: imaging o radiography  ultrasound prenatal  image of fetus, placenta and uterus  development of size of fetus  sex of baby  can determine congenital heart probs o chest x ray post natal  heart size  pulmonary vascular mark o EKG pre and post  transthoracic echo  probe placed in pt’s chest  sound waves come from probe and produce images  measure internal structures of heart  measure velocities of blood flow  estimates CA o Cardiac cath post natal  set of VS  height and weight  any allergies  iodineshellfish  head to toe  type and crossmatch for blood must be sent before cath  NPO

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H&H cardiac sedation check pedal pulses  may lose pedal pulses  mark the pulses risk of hypothermia  not enough warmth, organs start to shut down what is it  go through femoral artery up to heart to catheterize  more invasive  put kid under anesthesia  exposed to radiation  contrast dye injected to visualize post op  place on cardiac monitor  VS  head to toe  pedal pulses  monitor bleeding o not always seen as active bleeding o may see bleeding at site or ecchymosis at back of pt o saturated surgical dressing  maintain flat for 6 hours o extremity must remain straight o toddlers and school age may need close monitoring or restraints

CHD: Shunting o significant change in hemodynamics within heart change flow of blood o best understood as blood going from one area to another that it shouldn’t go through an abnormal opening within the heart o 2 types  left to right heart shunt  oxygenated blood*** no cyanosis  across to the right side of the heart  pushing blood against whole pressure against body o 120 pressure; systolic  forces blood to travel from area of high to low pressure  anytime blood going from one side to other, can lead to HF bc of fluid volume overload  right to left heart shunt  deoxygenated blood goes from right to left through abnormal opening within the heart  increase in PVR that may be caused by

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o increase in pressure o obstruction to blood flow  pulmonic valve  pulmonary artery o cyanosis o pressure will be very high in pulmonary artery bc lung of newborn is not expanded yet o instead of blood going to pulmonary artery it’s going to go back to left ventricle o consequences of shunts  cardiac shunts cause an imbalance of blood flow, changing the cardiac output to the lungs and systemtic circulation  an increase in pulmonary or systemic flow places the ventricles under stress, increasing oxygen consumption and metabolic demand  HF caused by  volume overload  pressure overload  decreased contractility  increasing metabolic demands HF in children: s/s  untreated cardiac shunts will result in left and right HF  tachy  weakness and fatigue  exercise tolerance  pale, cool extremities  htn  decreased urine output  edema, ascites, hepatomegaly  pulmonary congestion  tachy  dyspnea  nasal flaring  crackles in lungs  pink frothy sputum  cyanosis  hypoxemia results due to reduced cardiac output and an inability for gas exchange to occur  physiological changes will be seen over time o polycythemia  increase in numbers of RBC’s in whole blood  clubbing right sided HF  can’t send blood to pulmonary artery

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left sided HF  can’t send to systemic circulation  how do you know if they can’t tolerate exercise  poor feeding cardiac effects  acyanotic heart defects  pink baby: L to R  left to right shunt forces arterial blood flow from left to right  leads to HF, pulmonary congestion and pulmonary hypertension  neonates and children present with CHF and respiratory distress  examples include  patent ductus arteriosis o hole in the aorta  atrial septal defect  ventricular deptal defect cyanotic heart defects  R to L shunt blue baby  venous deoxygenated blood is shunted from right to left, bypassing the lungs and traveling straight to systemic circulation  deoxygenated blood in systemic circulation leads to cyanosis and hypoxia  examples include  tetralogy of fallot  transposition of great arteries  truncus arteriosus obstructive heart defects  anatomic narrowing of arteries obstructs blood flow leaving heart  pulmonary artery narrowed  obstruction leads to an increase in pressure within ventricles, while pressure beyond obstruction is decreased  undue pressure increases stress and workload of heart can lead to  decreased CA  HF  hypoxemia  examples  aortic stenosis o narrowing of aortic valve o most common is valvular stenosis o consequence is hypertrophy o surgical balloon dilation and repair of valve is required, but will not result in normal valve o signs  infant: signs of cardiac failure including tachy, hypotension, pallor, cyanosis, weight loss

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child: exercise intolerance, chest pain,, dizziness, exercise intolerance  coarction of aorta o narrowing of aorta near insertion of ductus arteriosis o increased pressure proximal to defect o decreased pressure distal to defect o bounding pulses in upper extremities o decreased/diminished pulses in lower extremities o development of extra blood vessels o s/s  pale skin  irritability  sweating  difficulty breathing  difficulty feeding o treatment  surgery  inflate balloon  pulmonic stenosis o narrowing of pulmonary valve or artery o most common is valvular stenosis o obstruction can occur BELOW or ABOVE valve o consequences are RV hypertrophy and hypoxemia o surgical balloon dilation and repair of valve needed but will not necessarily result in normal valve o blood will have hard time going from R ventricle to the lungs o valve that becomes stenotic and obstructed  no blood to lungs at all  question o Bryce is a child diagnosed with coarction of aorta. While assessing him, nurse zach would expect to find which of the following?  squatting position  absent or diminished peripheral pulses  cyanosis at birth  cyanotic “tet” episodes Congenital Heart Disease with Decreased Pulmonary Blood Flow  tetralogy of fallot  complex condition of several congenital defects that occur due to abnormal development of fetal heart during first 8 weeks of pregnancy  RAPS=tetralogy of fallot o multiple conditions combined

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o R: R ventricular hypertrophy  thick muscular RV develops due to increase in RV workload o A: aorta displacement  aorta situated above VSD between LV and RV o P: pulmonary stenosis o S: septal defect cyanosis will occur in this child: AFFLICT o A: activity cyanosis o F: fingernail changes o F: fatigue o L: life knee to chest; squat to help with blood return o I: inability to grow bc trouble feeding o C: cardiac sounds o T: trouble feeding treatment o stent pulmonary artery o patch opening in septum Cyanosis o if RV obstruction is severe, or if pressure in lungs high, large amount of deoxygenated blood passes through VSD and makes its way into aorta o deoxygenated blood traveling to systemic circulation will result in cyanosis o more blue blood traveling to systemic circulation means less blue blood traveling to lungs o all of the blood within heart will become deoxygenated medication o prostaglandin A: trying to keep ductus arteriosis open so it can send more blood to body TET spell o cyanosis occurs with activity such as crying, agitation or feeding o s/s  cyanosis  irritability  lethargy due to hypoxemia  murmurs  tachy  syncope o when you see this  child will squat  infant puts knee to chest

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Nursing Management  begins with diagnosis or birth of child with CHD o allow fam to grieve loss of perfect child o support parents o fear is child will die o assess parents level of understanding  educate about heart prob  provide age appropriate teaching to kid  allow child to express feelings and concerns  prepare child and fam for surgery  want to give o small feedings o extra vitamins o increase calorie intake as child tolerates food pre op  check ups to assess growth  check development of HR  assess parents ability to cope with diagnosis  assess signs of infection post op  intubated and ventilated  IV lines to monitor arterial and venous pressures  IV lines for fluids and meds  chest tube  infant: radiant heat warmers bc lose heat easily  pain management: IV opiods around the clock Med therapy  Dig o lowers HR and increases cardiac contractility o must count apical pulse before admin  hold for less than 70 in older child  hold for less than 100 in infant o administer 30 mins before meals or 1 hour after meals o monitor serum levels o monitor potassium***** o signs of toxicity  frequent vomiting  poor feeding  bradychardia****  Spironolactone o potassium sparing o admin with food o monitor potassium and sodium

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o monitor kidneys o cause false elevation in dig levels o teach to avoid high potassium diet Furosemide (Lasix) o give with food or milk o monitor BP o monitor kidney o electrolytes...