Pediatric Nursing Study Guide.

Pediatric Nursing Study Guide Includes topics about childhood diseases, growth and development, pediatric oncology nursing, and congenital diseases among others.

Infectious and Immune Disorders Function of immune system • 1st line of defense o Skin/mucous membranes o Passive immunity from mom o Maternal circulation/breast milk • Cannot produce immunoglobulins (antibodies) • Until approx. 2 mos. of age • Immune system not fully functional until 6 years of age • Those babies that are breast fed, usually have less ear infections • Stimulates production of antibodies against a specific foreign substance (antigen) • Contraindications o Anaphylaxis o High doses of steroids (<14 days) o Acute febrile illness – greater than 39 o Common cold/minor illness NOT contraindicated o Chronic illness (cancer) o Taking immunosuppressive drugs o Egg allergy – flu shots o Most up to date schedules on CDC.gov Purpose of vaccines, misconceptions • Misconceptions o Causes autism o Rotovirus vaccine is dangerous o Vaccines have toxic ingredients – led and mercury o Vaccines can fail o Vaccines can cause the actual illness o Parents can refuse vaccines • Types o Live (attenuated) – vaccines made from virus made from live virus o Killed (inactivated viruses) o Toxoids – diphtheria, tenus, - one type of vaccine – based on the toxin made from the bacteria o Human immune globulin – Igg Ige – weakened immune system and this helps them bring up their immune system o Herd immunity – vaccinate many to protect the few Communicability periods of disease • Incubation period – common cold = 1-5 days o Time of exposure to the time the time symptoms arrive

o Chicken pox = 21 days • Period of communicability – time it takes to transfer a disease from me to you • Prodromal period – beginings off an illness – feeling eh, scratchy throat • Sometimes difficult to tell the difference • Virus o Increased lymphocytes • Bacteria o Increased neutrophils o Left shift – some of the white blood cells shift to make it look bacterial infection Common viral and bacterial infections, treatment, and nursing care viral • Gastroenteritis o Vomiting/diarrhea ▪ Volume depletion • Intravascular space o Degree of dehydration ▪ Determined by physical exam ▪ Signs of dehydration – clammy – dry mucus membranes, dry skins o Treatment ▪ Mild/moderate • Zofran (ondansetron) • Oral hydration ▪ Severe • IV 20cc/kg isotonic solution • Coxsackie disease (infants and young children) o Hand/foot/ and mount disease ▪ Fever ▪ Sore throat ▪ Malaise ▪ Poor appetite ▪ Rash and mouth sores occur 1-2 days after the above symptoms ▪ Lasts about 1 week • Conjunctivitis – pink eye – last 7-10 days • Thrush o Yeast infection ▪ Oral (infants) ▪ Urogenital (infants/toddlers; diaper dermatitis) ▪ “Yeast infection” (adolescent girls) ▪ Intertrigo (skin folds of groin, armpits, torso) o Treatment ▪ Hygiene (limit moisture diaper area) ▪ Topical/systemic antifungals (nystatin) th • 5 disease

o Fever o Runny nose o Headache o Rash (slapped cheek) then spreads (comes and goes) o May last 2-39 days • Chicken pox • Measles, mumps, rubella • Roseola (6-18 months) o Sudden high fever (39.4-41.1) 3-5 days o Rash several hours to 2 days after fever is gone ▪ Blanches with pressure ▪ Neck and trunk, may have whitish ring, lasts 24-48 hrs • Monomucleosis (Epstein- Barr virus) o Causes ▪ Fever ▪ Fatiguge ▪ Sore throat ▪ Swlooen glands • Many have a rash (exanthem) • Most have fever • Most are accompanied by cold or flulike symptoms • Most transmitted by direct contact with droplets or airborne particles • Most can be prevented by immunization • Treatment is mostly symptomatic • Encephalitis is rare but can occur as a complication of most childhood viral infections • Febrile seizures (most common from 3 months-5 yrs) Bacterial • Strep throat /scarlet fever • Lyme disease (most common tic-borne disease) o Affects skin, musculoskeletal, CV, neuro systems ▪ Early: Vague flu-like symptoms/”bulls-eye” rash ▪ Neuro: Headaches, bell’s palsy, ataxia ▪ Musculoskeletal: Large joint arthritis (knee), joint/muscle pain • Pertussis (Whooping cough) o Catarrhal stage ▪ 1-2 weeks ▪ URI symptoms ▪ Paroxysmal • 2-4 weeks or longer ▪ Increased severity of cough (whoop sound). Cyanosis, distention of neck veins, salivation, tongue protrusion o Convalescent ▪ 1-2 weeks

▪ Symptoms lessen, cough may persist for months • Helminths (Worms) o Transmission ▪ Oral-fecal ▪ Ingestion contaminated host ▪ Skin penetration ▪ Bite of blood-sucking insect o Treatment ▪ Entire family ▪ Prevention ▪ Anti-worm meds po • Bacterial meningitis o Acute inflammation of meninges ▪ Bacteria enters subarachnoid space ▪ Inflammation response triggered ▪ Causes obstruction of blood flow • Increased ICP • Seizures • Hernation • Death o Infants <32 weeks gestation most at risk ▪ Temp instability ▪ Bulging anterior fontanel ▪ Shrill cry/irritability ▪ Gaze deviation ▪ Posturing/seizures ▪ NO nuchal rigidity o Older child ▪ Fever ▪ Headache ▪ Meningeal signs ▪ Brudzinski sign ▪ Kernig’s sign ▪ Nuchal rigidity • Most reliable • Bacterial infections o Older child ▪ Photophobia ▪ Vomiting ▪ Behavior changes ▪ Irritability ▪ Lethargy o Petechiae – little bumps that will not blanch

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o Purpura o These are both emergencies because they mess with clotting factors Medications that increase risk for infection o Corticosteroids o Chemotherapy o Tumor necrosis (TNF) inhibitors o Immunosuppressants Nursing considerations o Good hand-washing o Rest/avoid sports o Fever control o No sharing of utensils, cups, towels, etc. o Parental support o Serious bacterial infection ▪ IV/fluids ▪ Fever control ▪ Blood ▪ Urine ▪ LP ▪ X-rays ▪ Antibiotics • After all cultures taken Isolation precautions o Droplet isolation considerations ▪ eg. pertussis (whooping cough) ▪ Mimics other respiratory conditions ▪ Highly contagious o Airborne isolation considerations ▪ Tuberculosis ▪ Measles o

Integumentary Disorders General nursing care of secondary skin lesions Common infant skin variations • Cherry hemanigma – red moles • Port wine stain - Due to an abnormal aggregation of capillaries, a port wine stain is a type of vascular malformation (vascular birthmark). A port wine stain on the face is a sign of the Sturge-Weber syndrome.

• Mongolian spots • Salmon patch – stork bites • Seborrheic dermatitis – cradle cap • Contact dermatitis – skin rash caused by contact with a certain item

Nursing care of burns • Heat, chemicals, electricity, sunlight, radiation o 1st degree burns (superficial) o 2nd degree (partial thickness) o 3rd degree (full thickness) • Deep burns o White/waxy o Nerve endings destroyed o No cap refill in burned tissues o Fluid and serum protein loss o Eschcar o Skin grafts o Give H2 antagonist (stress ulcer) • Burns Treatment o 1st degree ▪ Cool compresses/aloe vera/symptom management o 2nd degree ▪ Thorough cleaning/silver sulfadiazine cream rd o 3 degree ▪ Fluids (prevent hypovolemic shock) ▪ CPR ▪ Protein loss replacement • Burns Nursing Care o Aseptic technique o Pain control o Communication with family o Child life • Nursing care and treatment of skin conditions from power point • Impetigo o Caused by Staphylococcus aureus, group A beta-hemolytic streptococci, or a combination of the two o Incubation period 7 to 10 days o Two forms ▪ Bullous ▪ Crusted o Diagnostic evaluation ▪ Appearance usually confirms diagnosis-honey crusted lesions o Therapeutic management ▪ Topical and/or oral antibiotics for 7 to 10 days o Nursing implications ▪ Good handwashing

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No daycare or school for 24 hours after antibiotic treatment Soak and wash crusts three times daily Use antibacterial soap at bath time Have child sleep alone Administer full course of antibiotic therapy

Celluliti s o Bacterial infection of the subcutaneous tissue and the dermis o Local manifestations ▪ Edema ▪ Erythema ▪ Pain ▪ Skin hot to touch o Systemic manifestations ▪ Fever ▪ Malaise ▪ Lymphadenitis ▪ Lymphangitis o Diagnostic evaluation ▪ Complete blood count ▪ Blood cultures ▪ Culture of affected area o Therapeutic management ▪ Initially intramuscular or intravenous does of antibiotics, then 10 days of oral antibiotics o Nursing implications ▪ Rest ▪ Elevate and immobilize the affected extremity ▪ Warm moist soaks every 4 hours ▪ Medications to control fever and pain as ordered ▪ Intravenous, intramuscular, or oral antibiotics as ordered ▪ Frequent handwashing Thrush o Overgrowth of fungus candidiasis ▪ Neonate cause: during delivery from infected vagina ▪ Older infant causes: immunosuppression, during antibiotic therapy, exposure to mom’s infected breast, unclean bottles/pacifiers • Nystatin Tinea Capitis o Usually children 1 to 10 years o Griseofulvin at least 6 weeks o Selenium sulfide shampoo 2x/week x2 weeks ▪ Erythema ▪ Scaling

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▪ Round patches of alopecia ▪ Pustules ▪ Kerion o Antifungal topical treatments (eg. Lotrimin) 2x/day x 4 weeks o Place 1 inch beyond borders to prevent spread ▪ Trunk ▪ Face ▪ Extremities Pediculosis captious - lice o Clinical manifestations ▪ Nits are visible and attached firmly to hair shaft ▪ Commonly found behind ears and at nape of the neck ▪ Intense pruritus ▪ Posterior lymph adenopathy o Diagnostic evaluation ▪ Identification of nits or lice on scalp o Therapeutic management ▪ Kill lice with a pendiculicide ▪ Remove nits ▪ Prevent spread and recurrence ▪ Recheck 7-10 days o Nursing implications ▪ Wash all child’s clothes (worn within last 2 days) and linens daily in hot water with detergent ▪ Stuffed toys and bedding that cannot be washed should be sealed in plastic bags for 2 weeks ▪ Brushes combs soak hot water ▪ Vacuum ▪ No fumigants Acne o Face, neck, chest, back o Excess of sebum ▪ Hormones ▪ Menstrual cycle ▪ Excessive sweat o Wash 2x/day o Topical benzoyl peroxide o Topical antimicrobial cream o Moderate: oral antibiotics, topical retinol, benzoyl peroxides o Nursing care ▪ Teach use of oil-free cleansers ▪ Encourage no picking

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▪ May apply very warm cloths ▪ Educate about myths Contact dermatitis o Caused by irritants ▪ eg. Poison ivy, diaper rash o Nursing care infants ▪ Wash without commercial wipes ▪ All folds of skin ▪ Remove all topical treatment/excrement ▪ Apply vitamin A, D, and/or zinc oxide ▪ Promote open diaper time/use no plastic diaper coverings o Older child ▪ Cleanse well ▪ Aveeno baths/calamine ▪ Atarax ▪ Antibiotics for bacterial overgrowth ▪ No dye/perfume lotions Eczema o Common chronic allergic inflammatory disease of the skin o Children with eczema may develop asthma o Thought to be genetically determined o Contributing factors ▪ Inherited tendency for dry, sensitive skin ▪ Allergy ▪ Emotional stress o Clinical manifestations in infancy (1 to 4 months) ▪ Erythematous areas of oozing and crusting on cheeks, then forehead, scalp, and extensor surfaces of arms and legs ▪ Papulovesicular rash and scaly red plaques become excoriated and lichenified o Clinical manifestations seen in childhood/adolescence ▪ Dry, scaly papular patches noted on flexor surfaces of the wrist, ankles, knees, and elbows; also noted in neck creases, on eyelids, and on dorsal surfaces of hands and feet ▪ Lichenification Diagnostic evaluation ▪ Family history of allergy, elevated immunoglobulin E levels, allergy test, and inspection of skin o Treatment ▪ Antiinflammatory corticosteroid creams and ointments ▪ Antihistamines ▪ Oral antibiotics if widespread skin breakdown or infection o Nursing considerations

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Bathe or shower daily with tepid water with mild soap only on nonaffected areas No bath additives such as baking soda, bubble bath, or bath oils Pat rather than rub skin dry Apply emollient such as Eucerin or Lubriderm immediately after bath No perfumed or scented lotions Apply wet wraps to severely affected skin after applying topical medications Use antibacterial soaps for handwashing Keep fingernails clean and short Avoid wool or constricting clothing, which can promote itching or trap perspiration Place cotton gloves or socks over the hands of infants or young children to prevent itching

Scabies o Transmitted by close personal contact with infected persons o Clinical manifestations ▪ Intense pruritus, especially at night and nap times ▪ Infants and young children may be irritable and restless and sleep fitfully o Clinical manifestations ▪ Burrows ▪ Papules, vesicles, and nodules are common ▪ In infants and young children: lesions often found on the head, palms, soles, and axillae ▪ In older children: lesions often found in the webs of the fingers, elbows, axillae, and groin and on the buttocks o Diagnostic evaluation ▪ Microscopic examination of scrapings of the lesions o Therapeutic management ▪ Scabicidal medications include permethrin 5% cream (Elimite), lidane (Kwell, Scavene), and crotamiton (Eurax) ▪ Oral antihistamines for itching ▪ Antibiotics only if secondary infection develops ▪ Soothing creams or lotions may also be used to reduce pruritus o Nursing implications ▪ Give child a warm soap-and-water bath ▪ Apply scabicidal lotion to body and head, avoiding eyes and mouth ▪ Leave lotion on for 8 to 14 hours before washing off ▪ Treat all family members and close contacts ▪ Change clothing, bedding, and towels daily; wash in hot water and dry in hot dryer

Respiratory Signs and symptoms of respiratory distress • Presence of retractions/ use of accessory muscles • Assurance of patent airway • Color • Cough • Behavioral changes Differentiate among the various breath sounds • Rales • Rhonchi

• Stridor • Wheezing • Diminished breath sounds • Grunting Asthma long-acting and short-acting medications • Nebulizers break down medications into particles that are dispersed through respiratory tract o Corticosteroids o Bronchodilators o Mucolytics • Handheld device that administers medication as needed o Metered dose (MDI) o Dry powder (DPI) • Medications administered o Corticosteroids o Bronchodilators • Nursing considerations o Education on proper technique based on MDI/DPI o Assessment of oral cavity for fungal infection o Education on medication side effects Nursing care and treatment of: CF • Inherited autosomal recessive genetic disorder o Mutation of the protein cystic fibrosis transmembrane conductance regulator (CFTR) gene regulates digestive secretions, sweat, and mucus production • Cysts and scarring of the pancreas prevent normal secretion of digestive enzymes and insulin • Excessive sodium absorption causes lungs to produce abnormally thick mucus, eventually blocking the exocrine glands • Risk factors o Caucasian o Genetic predisposition •

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Diagnostic evaluation o Sweat chloride test o Nutritional panel o DNA testing o Pulmonary function test o Chest and abdominal x-ray o Stool analysis Clinical manifestations o Salty-tasting skin o Frequent respiratory infections o Coughing o Wheezing o Failure to thrive o Bulky, greasy stools o Constipation o Blockage of exocrine glands leads to viscous mucus production affecting the gastrointestinal, pancreatic, pulmonary, and reproductive systems Therapeutic management o CPT with inhalation therapy three to four times daily

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BPD

o Exercise o Antibiotics o Mucolytic agents o Vitamins A, D, E, and K o Pancreatic enzyme replacements o High calorie nutritional management Nursing interventions o Frequent focused respiratory assessment ▪ Secretion amount, need for suctioning o Height and weight o Calorie count o Number, consistency, and ease of stools o Provide education to patient and family ▪ Medication management • • • • •

AKA chronic lung disease Occurs as a result of severe pulmonary tissue scarring from prolonged mechanical ventilation and oxygen therapy Seen most often in premature infants Clinical manifestations o Inadequate lung function hypoxemia, apnea, increased work ofbreathing Diagnostic evaluation

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• Asthma • • • •

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o History of prematurity, oxygen administration, and/or ventilation o Chest x-ray Therapeutic Treatment o Supportive care: infant will improve with time as lungs grow and selfrepair Nursing interventions o Frequent respiratory assessments o Adequate hydration o Oxygen/ ventilation as ordered o Infection prevention o Supportive symptom management o Emotional support to parents

Chronic inflammatory disease that affects small and large airways Often diagnosed with reactive airway disease prior to asthma Genetic predisposition Clinical manifestations o Shortness of breath o Persistent cough o Inability to speak without distress o Decreased interest in playing or exercise o Wheezing and/or diminished air entry o Tachypnea Diagnostic evaluation o Family history of asthma or allergies o Chest x-ray o Pulmonary function tests Common triggers o Animal dander o Grasses, pine trees, mold o Cockroaches o Dust mites o Paint fumes, aerosols, smoke of any kind o High altitude o Increased stress o Food allergies o Cold temperature/ change in weather o Exercise o Fragrances o Cigarette smoke, illicit drug use Medication Management

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Apnea

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o Short-Acting Medications ▪ Beta-2 Agonists (albuterol) ▪ IV/ oral corticosteroids (methylprednisolone and prednisolone) ▪ Anticholinergic (ipratropium bromide) ▪ Racemic Epinephrine o Long-Acting Medications ▪ Inhaled corticosteroids (fluticasone) ▪ Beta-2 agonists (formoterol fumarate) ▪ Anti-immunoglobulin E (IgE) ▪ Mast cell inhibitors (cromolyn) ▪ Leukotriene modifiers (montelukast sodium ▪ Methylxanthines (theophyline) Action plan o Divided into 3 zones o ▪ Apnea Green: peak flow measurement is within 80100%; child can participate in all daily activities ▪ Yellow: peak flow measurement is between 50-80%; child should slow down, drink fluids, be aware of increased risk of asthma exacerbation ▪ Red: peak flow measurement is below 50%; child should immediately seek medical treatment Asthma severity classifications and medication management o Mild intermittent: symptoms less than twice per week o Mild persistent: symptoms more than twice per week but less than once per day o Moderate persistent: symptoms occur daily o Severe persistent: continual symptoms Nursing interventions o Frequent respiratory assessments o Oxygen therapy, if applicable o Adequate hydration o Medication administration as ordered o Emotional support and reassurance to both parents and child o Clustered care to promote rest o Age and medical status appropriate play activities o Family and child education for individualized asthma action plan o Emphasize importance of carrying rescue medication at all times

Cessation of breathing for 20 seconds or longer or a shorter period Often accompanied by cyanosis and bradycardia

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• Croup •

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Most commonly seen with o Premature infants o Presence of infection o Temperature abnormalities o Gastric reflux o Immature central nervous system function Clinical manifestations o Apparent life-threatening episode characterized by apnea, color change, change in muscle tone, choking, or gagging in an infant who otherwise appears healthy Nursing interventions o Apnea monitoring while in hospital and when discharged home o Maintain a neutral thermal environment o Monitor closely while feeding o Family education in preparation for return home

General term applied to a broad classification of upper airway illnesses that result from inflammation, edema, and mucus production of the epiglottis, larynx, trachea, and bronchi • Caused by o parainfluenza virus o Influenza o Enterovirus o Respiratory synctial virus • Types of croup include o laryngotracheal bronchitis o acute spasmodic o bacterial tracheitis • clinical manifestations o Sudden or gradual onset of harsh metallic barking cough; sore throat; inspiratory stridor; hoarseness o Use of accessory muscles o Frightened appearance o Agitation o Cyanosis o Symptoms worse at night, better during the day • Diagnostic evaluation o Observation of clinical symptoms o Croup score Oxygenation status • Therapeutic management

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o Depends on symptoms, causative organism, and amount of respiratory distress o Humidity o Increased fluids o Antipyretics o IV fluids o IV antibiotics o Racemic epinephrine o Possible intubation Nursing interventions o Frequent respiratory reassessments o Administration of all ordered therapies o Comfort and education to patient and family

Epiglottitis • Infection of the epiglottis caused by Haemophilus influenzae type B • Assessment of the 4 Ds o Dyspnea o Dysphagia o Drooling o Distress • Epiglottitis is a medical emergency • Child will be in tripod position • Clinical manifestations o Sudden onset o Severe sore throat o High fever o Difficulty swallowing o Anxiety o Frightened appearance o Tripod positioning (classic sign) o Use of accessory muscles o Pallor or cyanosis o Tachycardia • Diagnostic evaluation o Examination and visual observation of the epiglottis most reliable diagnostic sign ▪ Contraindicated until emergency intubation equipment and qualified personnel are available o Elevated WBC o Lateral neck radiograph • Therapeutic management

o Constitutes a medical emergency and child will be hospitalized o Intubation o IV fluids o IV antibiotics o Antipyretics • Nursing interventions o Allow child to sit upright in tripod position or any way that the child is comfortable until intubated o Frequent respiratory reassessments o Administration of all ordered therapies o Comfort and education to patient and family Bronchiolitis • Acute viral infection affecting the lower airways • Occurs primarily in winter and spring • Respiratory syncytial virus (RSV) is most common cause • Adenovirus, rhinovirus, and parainfluenza are other possibilities • Occurs in children under 2 years of age o Infected infants are very symptomatic and routinely hospitalized • Pathophysiology o Viral progression from upper airways to lower airway, causing edema, mucus, and cellular debris which obstruct bronchioles o Infected clumps of cells destroy cilia o Blocked small airways cause atelectisis o Impaired gas exchange causing hypoxemia • Clinical manifestations o Tachypnea o Wheezing, crackles, or rhonchi o Intercostal and subcostal retractions with or without nasal flaring o Cyanosis o Irritability o Cough o Fever • Diagnostic evaluation o RVP- ELISA test o Chest x-ray • Nursing interventions o Frequent respiratory assessments o Symptom management ▪ Fever reduction ▪ Application of ordered oxygen ▪ Management of secretions o Provide adequate hydration o Isolation

o Family education and emotional support • **RSV prevention in high risk children with Synagis prior to RSV season • **Symptoms will likely last for more than a week and status of patient may change frequently Pneumonia • Lower airway infection • Source can be viral, bacterial or fungal • Clinical manifestation o Cough o Tachypnea o Fever o Shortness of breath • Diagnostic evaluation o Chest radiograph o Blood cultures o Gram stain and culture of sputum • Nursing interventions o Provide symptom management o Antibiotic administration o Maintain adequate hydration o Provide emotional support to child and family

Cardiac Signs and symptoms of pediatric CHF, nursing care • Clinical syndrome: heart’s inability to maintain sufficient cardiac output to meet the metabolic demands of the body • Four main signs o Tachycardia o Tachypnea o Enlarged heart o Enlarged liver • Generalized pallor • Diaphoresis • Murmurs • Cool extremities/weak pulses/slow cap refill • Poor appetite/FTT • Activity intolerance/fatigue • oliguria Acyanotic, cyanotic, acquired cardiac disorders, what they are, nursing care • Acyanotic o left to right cardiac blood flow

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Most common CHD Left to right shunt may be asymptomatic or murmur, SOB, FTT, feeding difficulties, systolic thrill

o Asd ▪ Also left to right shunt ▪ May be asymptomatic or murmur, increased size of right atrium o Aortic stenosis ▪ Narrowing or stricture of the aortic valve ▪ Clinical manifestations • Heart murmur • Exercise intolerance • Chest pain • Dizziness with prolonged standing o Coarctation of the aorta ▪ narrowing of descending aorta ▪ restricts blood flow leaving heart ▪ May be asymptomatic • B/p diff of 20 mm Hg upper/lower extremities • Full brachial/radial pulses, weak femoral pulses • Exercise intolerance/dyspnea • vertigo • epistaxis o Patent ductus arteriosus ▪ Caused by failure of the fetal ductus arteriosus to close completely after birth ▪ Can be present alone or in combination with other defects ▪ Left to right blood flow: Risk for chf ▪ Murmur, enlarged heart o Cyanotic o right to left cardiac blood flow o Tetralogy of fallot ▪ 4 defects • VSD • Pulmonary stenosis • Right ventricular hypertrophy • Overriding aorta o Tetralogy of fallot ▪ Systolic murmur in the pulmonic area ▪ Polycythemia

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▪ Metabolic acidosis ▪ Poor growth/poor feeders ▪ Exercise intolerance ▪ Clubbing of digits ▪ tet spells (hypoxia, pallor, tachypnea o Transposition of the great vessels ▪ Aorta arises from the right ventricle ▪ Pulmonary artery arises from the left ventricle ▪ Progressive cyanosis progresses to hypoxia, which progresses to acidosis ▪ Signs and symptoms of congestive heart failure ▪ Tachypnea ▪ Poor feeding/failure to grow o Hypoplastic left heart ▪ Abnormally small left ventricle noted at birth ▪ Heart unable to supply the oxygen needs of the body • Tachypnea, chest retractions, dyspnea • Cyanosis • Decreased pulses, poor peripheral perfusion • Increased right ventricular impulse • Signs and symptoms of congestive heart failure o Acquired cardiac disease o Rheumatic heart disease ▪ Group b strep causes heart valve damage ▪ Arthritis ▪ fever ▪ Erythema marginatum ▪ Subcutaneous nodules ▪ Sob ▪ Chest pain/arrhythmia/murmur ▪ Abd pain ▪ Rheumatic heart disease nursing care • Monitor for chf • Antibiotics (PCN is choice)) Erythromycin if allergic • Anti-inflammatory meds (ASA or corticosteroids) • Teach parents/teachers to screen for sore throat • Educate about dental prophylaxis • Potential valve replacement • Bedrest until ESR returns to normal o Kawasaki disease ▪ Multisystem affects skin, blood vessels, mucous membranes, lymph system ▪ Cause unknown but may be related to hx viral infection, toxic exposure ▪ Not contagious

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Complete cure possible but monitor for a year (risk of Mi) Kawasaki symptoms • high fever • conjunctivitis • enlarged lymph nodes • red lips • ”strawberry tongue” • swollen, red hands and feet • Extreme irritability • groin rash • Abnormal x-ray or echo • Increased wbc, lynphs, platelets ▪ Administer aspirin 80 to 100 mg/kg body weight per day as ordered while temperature is elevated ▪ Administer intravenous gamma globulin as ordered to reduce risk of coronary artery lesions and aneurysms ▪ Teach parents to avoid persons with viral illness while on ASA therapy o Sub-bacterial endocarditis ▪ inner layer of heart and vaves inflamed from strep or staph infection • Can be a sequel of bacteremia in a child with heart disease, especially in children with valvular disease • Clinical manifestations o Sudden onset with unexplained fevers /chills o Anorexia o Malaise o Myalgia/arthralgia o weight loss o Development of a new murmur o Roth retinal spots (early) o Sob o Petechiae • intense antibiotic therapy (monitor for antibiotic side effectsnausea/vomiting/diarrhea) • monitor for stroke, poor cardiac output and chf • prepare child and family for valve replacement • educate on prophylactic antibiotics for dental work, t & a • Digoxin and use of diuretics • Digoxin (lanoxin) o improves contractility of heart o improve cardiac output o improve perfusion and oxygenation o Digoxin guidelines

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check apical pulse for one minute do not give if HR less than 90 bpm for infants and 70 for older children given 2x per day do not mix with food; give water after to prevent tooth decay do not make up missed dose if more than 2 doses missed consecutively, contact physician toxicity • nausea and vomiting • Anorexia • Abd pain • Visual disturbances • Bradycardia • arrythmias • give poison control number to family

o Diuretics ▪ Lasix ▪ bumex ▪ aldactone (potassium sparing) ▪ diuril (Potassium sparing) o Cardiac cath care before and after • Preprocedure care o Age-appropriate teaching o Family support o Nothing by mouth order after midnight o Oral sedation as ordered o Baseline vital signs o Bloodwork as ordered o Pedal pulses • Post o Child should be positioned with affected leg straight for 4 to 6 hours after procedure o Intravenous fluids administered until infant or child is taking and retaining adequate amounts of oral fluids o Monitor for bleeding-feel under leg for blood o Monitor for arrhythmias o Monitor for infection o Medicate for pain as ordered o Assess insertion site o Assess for diuresis r/t dye

Fluids and Electrolytes Peds vs. adult fluid distribution • Neonates and young infants: larger extracellular fluid volume • Children younger than 2 years: greater amount of skin surface/body surface area • Water is lost through the lungs: higher respiratory and metabolic rates in early childhood • Infants: o Weight is 75% H2O o High metabolic rate + 40% body H2O located in ECF = potential rapid dehydration • Adults/older children o Weight is 55-60% H2O o More fluid in ICF = slower severe fluid depletion o Fluid distribution reached around aged 3 • In children younger than 2 years, the glomeruli, tubules, and nephrons of the kidneys are immature • The immature kidney is less able to concentrate urine in infancy • Children younger than 2 years have difficulty regulating electrolytes such as sodium and calcium • Specific gravity – 1.015 Dehydration types, nursing care, management

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Things that increase risk of dehydration o Increased extracellular fluid o Increased body surface area o Increased metabolism o Increased rate of peristalsis o Immature kidneys o Harder time compensating for acidosis because of decreased ability to acidify urine o Immature immune system, increased risk for infection Classification according to serum sodium concentration

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Isonatremic ▪ Most common in peds ▪ Serum sodium remains normal ▪ Water and electrolytes lost at same proportion o Hyponatremic ▪ Electrolyte loss > than water loss ▪ Serum sodium < 135 mEq/L o Hypernatremic ▪ Water loss > than electrolyte loss ▪ Serum sodium > 150 mEq/L Things that can cause dehydration o Gastrointestinal tract: vomiting, diarrhea, obstructive conditions, malabsorption conditions, motility disorders, nasogastric suction, esophageal atresia with tracheoesophageal fistula, imperforate anus o Endocrine system: fever, diabetic ketoacidosis, cystic fibrosis o Lungs: tachypnea o Heart: congestive heart failure o Skin: burns o Kidneys: renal failure o Hemorrhage Isotonic dehydration o Causes of isotonic dehydration ▪ Blood loss ▪ Surgery ▪ Volume loss (dehydration o Boluses ▪ 0.9% NS ▪ Lactated Ringers (LR) o Maintenance ▪ D5W ▪ D51/4 Hypotonic dehydration o Causes: ▪ Burns ▪ Pancreatitis ▪ Trauma ▪ Chronic malnutrition ▪ Diuretics ▪ Excessive sweating CF o You would have less sodium o Treatment: Mostly 3% saline to correct, mannitol o If you have hyponaterium- you want to pull fluid from the cells and you can do that with hypertonic solution – 3% saline

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Hypertonic dehydration o Causes ▪ Severe dehydration ▪ Diabetes insipidus ▪ Heat stroke ▪ End-stage renal disease o Treatment ▪ ½ NS (0.45%) ▪ ¼ NS (0.225%) ▪ 1/3 NS (0.33%) Stages of dehydration o Mild dehydration = up to 5% of body weight lost (40 to 50 mL/kg) o Moderate dehydration = 6% to 10% body weight lost (50 to 90 mL/kg) o Severe dehydration = 10% or more body weight lost (100+mL/kg) Degrees of dehydration

Assessment of dehydration, urine output • Pathophysiology of dehydration o Reduced volume intake or excess fluid volume loss o Rapid reduction of extracellular fluid o Electrolyte imbalance o Loss of intracellular fluid o Cellular dysfunction o Hypovolemic shock o Death o Isonatremic dehydration is the most common type of dehydration in children • Nursing assessment o Intake and output o Urine output and specific gravity o Weight o Stool/vomitus o Sweating o (fever or other causes) o Serum electrolytes and blood gases

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o Intake and output o Urine output and specific gravity o Weight o Stool/vomitus o Sweating o (fever or other causes) o Serum electrolytes and blood gases Management of dehydration o First priority is restoration of circulation by rapid expansion of extracellular fluid. o Medical management depends on accurate identification of the degree of dehydration in addition to physical signs and symptoms. Po first and then sublingual o Give pedialight to 9 month old for only 12 hours o Treatment of extracellular volume deficit is administration of fluid containing sodium by oral or intravenous routes. o If the child is awake and alert, oral hydration is attempted; if not, then intravenous replacement. o Replacement of loss over a 24-hour period in addition to maintenance fluid o Potassium is replaced only after urine output is adequate o Sodium bicarbonate may be added if metabolic acidosis is present Maintence o Daily fluid requirements by body weight ▪ 3-10 kg 100 mg/kg ▪ 10-20 kg 1000 mL + 50 mL/kg for each additional kilogram between 10 and 20 kg ▪ 20+ kg 1500 mL + 20 mL/kg for each additional kilogram over 20 kg o Minimum urine output by age group ▪ Infant and toddlers: >2 to 3 mL/kg per hour ▪ Preschoolers and young schoolchildren: >1 to 2 mL/kg per hour ▪ Older schoolchildren and adolescents: 0.5 to 1 mL/kg per hour Rehydration o For mild or moderate dehydration, oral rehydration is the first intervention (if child is alert enough to take in oral fluids) o For severe dehydration, intravenous fluids are required; important to monitor carefully to prevent fluid volume overload Nursing interventions o Frequently monitor the child’s condition o Frequently assess hydration status o Take vital signs often o Monitor intake and output

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Monitor urine output (should have a minimum of 1 to 2 mL/kg per hour) o Administer oral and intravenous fluids safely o Monitor child’s weight o Observe infection control procedures o

Gastrointestinal Alterations Peds vs. adult differences in the GI system • Newborns (birth to 1 month) o Minimal saliva o Inadequate digestive enzymes (amylase, lipase, trypsin until 4 mos. of age o More watery stools (decreased absorption of water from decreased intestinal surface o Suck/swallow are reflexes ▪ Voluntary swallowing about 6 weeks • Infants (1 month-1 year) o Pace feeding to avoid choking o Cardiac sphincter of stomach is relaxed at birth, allowing mild, occasional regurgitation of stomach contents o Maternal iron stores gone by 6 months ▪ Foods start with iron-fortified cereal, then veggies, then fruits, then proteins • Toddlers o Toilet training o Need fewer calories o Picky eaters • Preschoolers o By end of preschool age, GI tract mature with poops to prove it o Fewer calorie needs as well • School-age and older o By age 6, full strength of hydrochloric acid in stomach GI tract fully mature with formed poops to prove it Nursing assessment and care of structural disorders, inflammatory disorders, obstructive disorders, and those labeled “other” • Structural disorders o Imperforated anus ▪ Includes several forms: • Absence of patent anorectal canal • Severe narrowing of anal canal • Fistula (from distal rectum to perineum or GU system

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Diagnosis is usually made at birth or during the newborn assessment when fails to pass stool ▪ Surgery ▪ Clinical manifestations • Absent anal opening • Abdominal distention • Vomiting • Absence of meconium • Presence of meconium in urine Diaphramic hernia o Protrusion of intestines and abdominal structures through an opening in the diaphragm muscle into the thoracic cavity o Need surgery Hernias o Umbilical hernia ▪ Occurs when fusion of the umbilical ring is incomplete at the point where the umbilical vessels exit the abdominal wall ▪ 90% of all umbilical hernias close by age 5 years ▪ Failure to close naturally necessitates surgical intervention o Inguinal hernia ▪ Protrusion of the bowel into the groin ▪ Prompt management of inguinal hernia to avoid incarceration Gastric reflux o The return of gastric contents into the esophagus from a relaxation of the lower esophageal sphincter o Occurs at any time and is not necessarily related to having a full stomach o Regurgitation increases in frequency and often results in delayed growth o More common in premature infants and in children with neurological impairments o Often resolves without surgical intervention by 12 to 18 months of age o Reflux of stomach contents can lead to aspiration, resulting in frequent bouts of pneumonia, respiratory airway disease, color changes during feeding, apnea, or hematemesis o Therapeutic management depends on severity of symptoms: ▪ Diet ▪ Positioning ▪ Medications ▪ Surgery Cleft lip and palate

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o Two distinct facial defects that can occur singly or in combination o Defects occur during embryonic development o Cleft lip results from failure of fusion of lateral and medial tissues forming the upper lip occurring around 7 weeks of gestation o Nursing considerations ▪ Assessment of the family’s reactions is an integral part of the overall nursing assessment o Preoperative care ▪ Continuously assess respiratory status during feedings ▪ Feed infant in upright position ▪ Feed infant slowly, burp frequently ▪ Alternate feeding devices: elongated nipple or breast shield ▪ Assess degree of cleft and ability to suck ▪ Encourage parents to verbalize fears, concerns, and negative emotions ▪ Refer to community resources and parent support groups o Therapeutic management is based on the severity of the defect o Team approach used in the management of the child with a cleft lip/cleft palate o Surgeons Orthodontists o Nurses Speech therapists o Geneticists Occupational therapists o Psychologists/psychiatrists Ear/nose/throat physicians Audiologists o Pediatricians o Postoperative care ▪ Clean lip from suture line outward after feeding and as necessary ▪ Apply antibacterial ointment as ordered ▪ Use elbow restraints to keep the infant from putting fingers in mouth or touching the surgical site ▪ No tooth brushing for 1 to 2 weeks ▪ Place infant in a supine or side-lying position on the unaffected side to avoid excessive contact with bed linens ▪ Analgesics and sedatives as ordered ▪ No oral temperature assessment ▪ No straws, pacifiers, spoons, or fingers in or around mouth for 7 to 10 days ▪ Cleft lip: resume preoperative feeding techniques ▪ Cleft palate: liquids can be taken from a cup, no straws; soft foods can be taken off the side of the spoon; child is not allowed to feed self Tracheosopheal fistula or atresia

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o Malformation that results from failure of the esophagus to develop as a continuous tube during the fourth to fifth weeks of gestation o Three “Cs” Coughing, choking, cyanosis o First feeds should always be observed by the RN. If three “Cs” noted, stop feed, and notify HCP immediately Inflammatory disorders o Necrotizing entrocolitis ▪ Inflammatory disease of the intestinal tract that primarily occurs in premature infants ▪ Is potentially life threatening and has a 40% mortality rate ▪ Can be caused by several factors: • Intestinal ischemia • Bacterial or viral infection • Immaturity of the gut o Celiac disease ▪ Gluten breaks down into gliadin in the small intestine ▪ Intestine is unable to digest gliadin ▪ Accumulation of glutamine causes toxic effect on the mucosal cells ▪ From here either the villi of the intestine will atrophy, leading to malabsorption of fat calories, carbohydrates, and vitamins ▪ The child will go into celiac crisis, which causes severe dehydration and diarrhea o Appendicitis ▪ Inflammation of the end of the cecum ▪ McBurney’s point tenderness ▪ Loss of appetite ▪ May have fever ▪ May have nausea/vomiting ▪ Rupture possible o Chrons disease ▪ Inflammation of all layers of GI mucosa • Any portion of GI tract o Bleeding/ulceration ▪ Diarrhea, weight loss, bloody stools, abd pain, anemia, dehydration, fever • Biopsy, stool analysis, bloods ▪ Rest, fluids, anti-inflammatory meds, surgery, diet changes (no sharp cheeses, spicy foods, blackened/smoked meats, raw fruits and veggies, fried foods o Ulcerative cholitis ▪ Only found in colon ▪ Symptoms same as Crohn’s, but has urgent diarrhea ▪ Workup/bloods the same as Crohn’s

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Obstructive disorders o Pyloric stenosis ▪ Occurs when the circular areas of muscle surrounding the pylorus hypertrophy ▪ Stenosis of passage between the stomach and duodenum, partially obstructing the lumen of the stomach ▪ Lumen becomes inflamed and edematous, which narrows the opening until the obstruction becomes complete ▪ Cause unknown ▪ Affects firstborn children and males most often ▪ Symptoms occur 2 to 4 weeks after birth (olive) o Intussusception ▪ Telescoping of part of the intestine into an adjacent distal portion of the intestine ▪ 6 months-3yrs, (rare after 3 years) ▪ Abrupt onset of acute abdominal pain, vomiting, alternating with periods of comfort ▪ Develops “current jelly”-like stools ▪ Palpable mass may be present in right upper quadrant or mid to upper abdomen o Malrotation and volvulus ▪ Caused by abnormal rotation of the intestine around the superior mesenteric artery during embryologic development ▪ May present in utero or may be asymptomatic throughout life ▪ Is the most serious type of intestinal obstruction: if the intestine undergoes complete volvulus, loss of blood supply will result in intestinal necrosis, peritonitis, perforation, and death Others o Bilary atresia ▪ Bile ducts blocked, creates liver damage ▪ Most common pediatric liver disease necessitating transplantation ▪ Clinical manifestations • Infants are usually term and appear healthy at birth • Jaundice persists beyond 2-6 weeks of age, with elevated bilirubin levels • Urine may be dark • Stools become gray or putty colored • Hepatomegaly is present early in the disease • Infant bruises easily • May have intense itching • May have prolonged bleeding times • Failure to thrive and malnutrition occur as the destructive changes progress • Abdominal distention

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Diagnostic evaluation • History • Physical findings • Blood work (including liver function tests) • Bilirubin level • Abdominal ultrasound • Liver biopsy ▪ Therapeutic management • Surgery to promote bile drainage and maintain liver function; while this surgery (Kasai procedure) improves prognosis, complications of liver disease progress and often necessitate transplantation.

▪ Nursing considerations • Goal of nursing care is to sustain the child in optimal condition until a liver transplant can be achieved o Nutritional support: administer total parenteral nutrition and fat-soluble vitamins A, D, E, and K as ordered o Skin care o Prevention of complications: infection, ascites, bleeding, encephalopathy o Developmental and parental support o Malabnsorbtion syndrome: short bowel syndrome ▪ Decreased ability to digest and absorb a regular diet because of a shortened intestine ▪ Extent and location of the involved bowel determine the severity of the disorder ▪ Causes include: • Necrotizing enterocolitis • Inflammatory disorders • Intestinal malrotation • Atresia • Congenital bowel anomalies ▪ Nursing considerations • Depends on the underlying cause • Prevention of dehydration/hydration maintenance • Oral care to prevent effects of hydrochloric acid on teeth • Nothing by mouth order if blockage or obstruction is suspected • Family teaching: see dehydration • Assess hydration status frequently • Take vital signs often • Monitor intake and output • Monitor urine output (should have a minimum of 1 to 2 mL/kg per hour) • Administer oral and intravenous fluids safely

• Monitor weight • Observe infection control procedures o Constipation ▪ No poop for 7 days or small hard stools with cramping ▪ Limited fluid intake, sedentary lifestyle, poor fiber intake, increased dairy ▪ Chronic and severe: Lead poisoning, underactive thyroid, celiac disease, abnormal calcium levels ▪ Encopresis ▪ Increase fiber (fruits, veggies, grains, fluids) ▪ Stool softeners ▪ Enemas ▪ Laxatives o Failure to thrive ▪ Secondary to a medical or emotional/affective disorder ▪ 2 or more consecutive plot points on growth chart below 5th percentile ▪ Many causes (eg. Malabsorption disease, mental health, neglect, family issues)