Week 5 [PEDS] - peds PDF

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Neuro ATI 12,13,14,29 Renal 24,25,26

Week 5: Renal and Neuro

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● Extracellular and intracellular balance (PUMP-K-IN ) ● Sodium: ECF: more outside > ICF: less inside ● Potassium: ECF: less outside < ICF: more in the cell ● Calculation of Daily Maintenance Fluid Requirements ○ Example 1: Daily Fluid Calculation ■ Child weighs 32 kg ■ 100 x 10 for first 10 kg of body weight = 1000 ■ 50 x 10 for second 10 kg of body weight = 500 ■ 20 x 12 for remaining body weight = 240 ■ 1000 + 500 + 240 = 1740 ml/24 hr ○ Calculating normal urine output ■ Note: The method used to measure normal urinary output is 1–2 mL/kg per hour. ■ Practice: If your 10 kg patient had 180 ml of urine in your 12 hour shift, what would be your intervention? TYPES OF DEHYDRATION Isotonic-most common ○ Loss of water and salts equal Hypotonic-electrolyte deficiency ● Electrolyte loss is greater than water loss. ● Blood sodium is than electrolyte loss. CALCULATING NORMAL URINE OUTPUT ● Method used to measure normal urinary output 1-2 ml/kg per hour ○ EX: If your 10kg patient had 180 ml or urine in your 12 hours shift, what would be your intervention?

Dehydration Mild

Moderate

Severe

Weight loss

3-5% infants 3-4% children

6-9% infants 6-8% children

Greater than 10% infants and children

Manifestation s

Behavior, mucous membranes, anterior fontanel, pulse, and BP within normal limits, cap refill greater than 2 seconds, possible slight thirst

Cap refill 2-4 seconds, possible thirst and irritability, pulse slightly increased, dry mucous membranes, decreased tears and skin turgor, slight tachypnea, normal to sunken anterior fontanel

Cap refill greater than 4 seconds, tachycardia, orthostatic BP, extreme thirst, dry mucous membranes and tented skin, hyperpnea, no tearing, sunken eyes, sunken anterior fontanel, oliguria or anuria

Interventions

Oral rehydration

100 ml/kg rehydration fluid

Replacement of diarrhea losses with 10ml/kg each stool

● Genitourinary System – A&P ○ Urinary System ■ Excretes Wastes ■ Maintains acid-base, fluid, and electrolyte balance ■ Comprised of: ● Kidneys ● Ureters ● Bladder ● Urethra ■ Outer cortex ● Composed of the glomeruli and convoluted tubules of the nephron and blood vessels ■ Inner medulla ● Composed of the renal pyramid ● Pediatric Differences ○ All nephrons present at birth ○ Renal growth ○ Most takes place during first 5 years ○ Full size by adolescence ○ Renal efficiency ○ Increases as child matures ○ Bladder capacity and control ○ Increases from 20 to 50mL at birth to 700mL in adulthood ○ Children less than 2 years old cannot maintain bladder control due to insufficient nerve development ○ Functionally immature until puberty ○ Genitalia (except clitoris in girls) enlarge gradually through childhood ● Nursing Care ○ Obtain daily weights ○ Measure intake and output ○ Assess hydration status ○ Laboratory tests include specific gravity, hematocrit, blood urea nitrogen (BUN), creatinine, Na+, K+ and CA++ ○ Assess type of acid-base disturbance ○ Administer oral clear liquids as ordered (1–2 oz every hour) ○ Start an IV for fluid and electrolyte replacement as ordered ○ Ensure that the child has voided prior to administering intravenous Potassium (K +) ○ Cleanse perineal area and apply protective topical ointment ○ Encourage parents to be involved in the care of child ○ Educate parents about signs and symptoms of dehydration, re-hydration, and when to call the doctor ○ Encourage parents to be compliant with follow-up appointment(s) ● Normal Characteristics of Urine ○ Color range ○ Clear ○ Newborn production: about 1-2 ml/kg/hr ○ Child production: about 1 ml/kg/hr ● LAB ○ pH: 5.0-9.0 ○ Specific gravity: 1.001-1.035 ○ Protein: 5 min call 911 ○ Use antipyretics and cooling measures ○ If this is a first time seizure, the doc should be notified even if it is only a few seconds ○ Rare after 5 years old and more common in males ○ Usually not treated with anticonvulsants because seizures usually end before they get to ER ● Epilepsy: chronic disorder. 2 seizures in 24 hours ○ Status epilepticus ■ Seizures last more than 30 min ■ Give prescribed meds slowly ● Nursing care ○ Protect from injury ○ Document ○ Teaching: meds, restrictions, triggers ● Tx for seizures ○ Ativan-lorazepam ○ Diazepam-diastat (can be given rectally) ○ Phenobarbital or phenytoin ○ Remind parents not to stop once the seizures are controlled until directed by a doctor ○ Other types of tx: vagal nerve stimulator, ketogenic diet ○ Also consider that as children grow, their doses may change. Must monitor blood levelsphenobarbital ○ Decrease in dosage for long term use may begin when pt has been seizure free for 2 years and EEG is normal ● Care ○ Prevent injury during a seizure ○ assist to the floor and placed in a side lying position. ○ Clear the area of any objects that might cause harm to.

Intracranial Infections Bacterial (septic) Meningitis ● More dangerous/contagious ● Group B streptococcus and gram negative enteric bacilli more likely cause in newborns ● Neisseria meningitis 2 mos-12 yr: can also cause meningococcemia ● Also caused by e coli: mostly for under 2 months ● H influenzae B and strep pneumoniae are now less common because of vaccination ● Fever, vomiting, irritable, hemorrhagic rash, headache, nuchal rigidity, seizures, photophobia Lab tests: ● CSF analysis, cloudy color, elevated WBC, elevated protein, decreased glucose, +gram stain

Tx: ● abx, corticosteroids: dexamethasone, analgesics Viral (aseptic) Meningitis ● Does not appear as ill as the child with bacterial ● Caused by enteroviruses, mumps, varicella, HIV, HPV ● Irritable, fever, lethargy, headache, may have stiff neck or back pain, photophobia Lab tests: ● clear color, slightly elevated WBC, normal or slightly elevated protein, normal glucose, -gram stain ● Usually resolves in 3-10 days Tx ● abx until bacterial is ruled out Both diagnosed by lumbar puncture review procedure ATI p 60 ● Spinal needle in subarachnoid space between L3 and L4 or L4 and L5 ● Measures spinal fluid pressure and collects CSF ● Nursing actions ○ Void before procedure ○ Topical anesthetic for 45 min-1 hour ○ Place pt in side lying with head flexed and knees drawn up to chest ○ Can be sedated with fentanyl and midazolam ○ Lido injected ○ Provide takes pressure readings and collects 3-5 test tubes of CSF Nursing priority-start antibiotics Meningococcemia- most severe Neisseria Meningitidis. – Immune response to endotoxins of the organisms. Meningitis ● If petechial or purpuric rash-need immediate medical attention! ● Isolate as soon as meningitis is suspected--droplet ● Give abx until bacterial is ruled out ● Review assessment and nursing care ati p 59-60 ● The child with bacterial meningitis may assume an opisthotonic position, with the neck and the head hyperextended, to relieve discomfort ● Kernig sign ○ raise the child’s leg with the knee flexed. ○ Then extend the child’s leg at the knee. ○ If any resistance is noted or pain is felt, the result is a positive Kernig sign. ○ This is a common finding in meningitis. ● Brudzinski sign ○ flex the child’s head while in a supine position. ○ If this action makes the knees or hips flex involuntarily, a positive Brudzinski sign is present

Encephalitis ● Generalized brain inflammation ● Fever, altered mental status Reye Syndrome ● Affects liver and brain ● Associated with aspirin use and flu ● n/v, mental status changes ○ lethargy, irritability, combativeness, LOC ● Seizures, progressive unresponsiveness ● May have elevated liver enzymes AST, ALT ● Diagnostic procedures ○ Liver biopsy and CSF analysis ● Meds: mannitol Guillain-Barre Syndrome (post infectious polyneuritis) ● Progressing muscular weakness, areflexia ● Self limiting ● Immunoglobulin, mechanical ventilation ● Headaches ○ Benign (migraine, inflammatory, and tension) and structural causes, such as a tumor Structural Defects Microcephaly ● small brain with head circumference below 3rd percentile on growth curves Hydrocephalus ● Nursing care ○ Preop: positioning, provide skin care, meeting nutritional needs, providing emotional support ● Communicating hydrocephalus: ○ no blockage. ○ Either with over production of CSF or problem with absorption. ○ The CSF flows freely, but absorption in the subarachnoid space is impaired ○ In communicating hydrocephalus, an excessive amount of cerebrospinal fluid accumulates in the subarachnoid space, producing the characteristic head enlargement seen here. ○ Note the large forehead and facial features that seem small for the size of the head. ○ When observing the child with hydrocephalus, look for a downward deviation of the eyes in which the lower half of the iris is hidden by the lower eyelid (sunsetting eyes). ○ This finding occurs in severe hydrocephalus, but is not present in this child. ● Non-communicating: obstruction. Majority of cases. Obstruction in the ventricular system ○ Congenital malformation ■ Myelomeningocele: type of spina bifida, often have hydrocephalus ■ Dandy-walker syndrome: posterior fossa blocked by cyst ■ Chiari malformation: foramen magnum is blocked causing CSF build up ■ Aqueduct of sylvius ● Non-congenital ○ Intraventricular hemorrhage in premature infants ○ Post infectious meningitis ○ Brain tumors ● Clinical manifestations ○ Newborns and infants: bulging fontanels, increased head circumference, sun set eyes, high pitched, cat like cry, visible scalp veins ○ Children: Headache, visual disturbance, n/v, pupils sluggish, decrease in consciousness, seizures, cushing's triad (widening pulse pressure, bradycardia, irregular RR) ○ What symptoms do you think the parents will notice?

■ Children can verbalize their head hurts. “My shunt hurts”. Infants tolerate ICP better because the skull expands at fontanelles. Body is “adapting” to the problem ● Tx: ○ ventriculoperitoneal shunt review post op care. Review ss malfunction and infection ○ A ventriculoperitoneal shunt system consists of four parts: a ventricular catheter, a pumping chamber or reservoir, a one-way pressure valve, and a distal catheter. ○ A shunt, commonly used to treat children with hydrocephalus, is often placed at 3 to 4 months of age.

● Nursing care ○ Postop: ○ positioning, assessing VS, providing incision care, monitoring for signs of shunt malfunction, increased intracranial pressure, infection Neural Tube Defects ● Lumbosacral myelomeningocele is caused by a neural tube defect in which the vertebral column is incompletely closed. ● The meninges (and sometimes the spinal cord) protrude as a saclike structure. ● Observe leakage of cerebrospinal fluid.

● Effects: ○ lower extremity weakness, bowel and bladder control issues, ambulation difficulties, hydrocephalus ○ Anencephaly, encephalocele, spina bifida occulta, spina bifida cystica, meningocele ○ Myelodysplasia: congenital spinal malformation Spina Bifida ● Surgery to close the repair usually occurs within 24-48 hours. Some cases can be repaired in utero--

may need VP shunt ● Ongoing therapy ○ Mobility braces, wheelchair ○ Neurogenic bowel and bladder ● More difficult to walk as the patient gets bigger. ● Bowel and bladder becomes more problematic as children get older. ● Remember that most do not have mental delays. Craniosynostosis ● Premature closure of cranial suture ● Positional Plagiocephaly ● Neonatal Abstinence Syndrome ● Neurofibromatosis Cerebral Palsy ● Nursing care: nutrition, mobility, skin integrity, safety, growth and development, parental knowledge, emotional support ○ Community care ■ Case manager to coordinate: finance, mobility aids, therapies ■ Therapies: speech, physical, occupational ■ Family support ■ School nurse coordination ■ Transition planning Injuries of the neurologic system Mild ● No or brief LOC. headache, memory loss, unsteady, tired Moderate ● 5-10 min LOC, headache, nausea, GCS 9-12 Severe ● LOC of more than 10 min ● GSC less than 8 ● Amnesia for more than 24 hours preinjury ● Coma ○ Nursing care ■ Maintain cerebral perfusion ■ Minimize increasing intracranial pressure ■ Prevent complications ■ Provide emotional support

Head Injury ● Major cause of childhood deaths ● It is not only their anatomical differences, but also the teenage perception that they are invincible. This is referred to as the personal fable. Injury is the greatest health hazard for adolescents. Injuries are twice as common in boys than girls. ● What activities do kids do that can increase their risks? ● Motorized vehicle crashes are the number one source of unintentional injury and death. ● Falls – leading cause of head injuries under 5 years Concussion SS ● headache, slowness i thinking, acting, speaking, fatigue, memory problems, loss of balance ● Mild brain injury, but can lead to more problems if a second injury occurs before the brain has healed. Transient and reversible. ● What is “Second impact syndrome”? Nursing care for all head injuries ● Assess neuro status, LOC ● Monitor VS ● Observe breathing ● Observe for pain ● Report any sign of decreased oxygenation or increased intracranial pressure immediately Cerebral Contusion - Bruising of the brain secondary to blunt trauma - Can be either coup or countercoup injuries - May involve tearing of brain tissue and may lead to areas of necrosis or infarction - What are the differences between concussion and contusion? - If there is a skull fracture, theres an increased risk of bleeding

Head Trauma Subdural Hematoma (between the layers of the dura mater) - Between dura and cerebellum - Result of head trauma such as falls, MVA, or shaken child syndrome - Symptoms may appear after 24-72 hours - Change in LOC, Headache, N/V, retinal hemorrhage, pupil on side of injury may be dilated - Prognosis poor Epidural Hematoma (between skull and outer layer of dura mater) - Between dura and skull - Almost never occurs in children less than 4 y/o. Blunt trauma such as MVA, assault, baseball injury - Delayed onset followed by rapid change in mental status - Headache, Fixed dilated pupils, s/s increased ICP - Prognosis good Why is a lumbar puncture not a good idea on a trauma or head injury?

Shaken Baby - Physical abuse - Countercoup injury - Subdural hematoma - Retinal hemorrhage - Seizure - Check baby for fractures in the rest of their body - Shaken Baby=Subdural S=S - DCFS involvement - The infants head has an increased range of motion compared to an adults with insufficient

musculoskeletal support.

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Countercoup injury

Drowning/near drowning - Drowning is the second leading cause of accidental death in children - Death occurs from asphyxia while submerged - Can occur with even small quantity of water (even as little as a pail of water) - Near-drowning: survived at least 24 hours after submersion Hypoxic-Ischemic brain injury (drowning) - Parent education - Household risks: buckets, toilets, standing water - Pool owners: fencing, learning CPR, alcohol/swimming risk...