Peds Final

segar's formula - on exam and final

used to determine the amount of fluid to give for maintenance ic for dehydration, divide total 24 hour amount by 24 hours to get ml per hour

check clinic educt

0-10kg 100ml/kg/24 hours

11-20kg 50ml/kg/24 hours

>20kg 20ml/kg/24 hours

uses 100ml/kg for first 10 kg, then use 50ml/kg for second 10 kg, then use 20ml/kg for rest weight

percent weight loss

check clinic educt

((normal weight- current rate) / normal weight) x 100

minimum urine output/expected fluid output

check clinic educt

1ml/kg/hr

more than minimum okay, weigh the diaper

why does dehydration effect kids more?

they have more percent water in the extracellular space which is one step away to be lost via kidneys, adults have it in intracellular fluid aka 2 steps away from kidney

rotavirus vaccine

prevents rotavirus that causes diarrhea

crying after pooping

painful or diaper rash

typical causes of dehydration

limited intake, fluid loss through: urinary, GI, skin and respiratory

fluid loss onset <3 days

EFC 40-50%

ICF 25%

fluid loss onset >7 days

EFC 50%

ICF 50%

more fluid is being pulled out of cells at this point

mild dehydration and thirst

normal thirst, usually not enough

moderate dehydration and thirst

drinks eagerly

severe dehydration and thirst

intense, but may be unable to drink enough

LOC - Mildly ill

alert and active

LOC - moderately ill

restless irritable anxious

LOC - severe illness

drowsy lethargy

mild illness vitals

normal HR or mild increase, BP normal

moderate illness vitals

tachycardia, BP normal or slightly low, othrostatic hypotension

severe illness vitals

rapid and thready HR, low BP

minimum expected systolic BP

70 + (2x age in years)

until adult normals

skin assessment dehydration mild

pale, dry, normal turgur

skin assessment dehydration moderate

pale/grey, poor turgur=, doughy

skin assessment dehydration severe

mottled tenting

fontanel assessment dehydration mild

usually normal (none after 18 months)

fontanel assessment dehydration moderate

may be sunken (none after 18 months)

fontanel assessment dehydration severe

sunken (none after 18 months)

dehydration assessment eyes mild

tearing with crying

dehydration assessment eyes moderate

slightly sunken eyes, decreased or no tears

dehydration assessment eyes severe

sunken eyes with dark circles, no tears

dehydration assessment mucous membranes mild

normal, slightly dry

dehydration assessment mucous membranes moderate

dry

dehydration assessment mucous membranes severe

parched, cracked

dehydration assessment perfusion mild

cal refill >2 sec, normal pulse

dehydration assessment perfusions moderate

cap refill 2-4 secs, weak, rapid pulses

dehydration assessment perfusions severe

cap refill >4 sec, pulses thready, cold extremities

mottled

spotted or blotched in coloring due to poor perfusion or cold

dehydration assessment labs

odium levels, BUN and Cr, Hct

BUN

goes high with dehydration because is more concentrated

Creatine

shows how kidneys are clearing, if dehydrated would be normal, if kidney disease then could be off

hospital treatment of severe dehydration

initial IV bolus, monitor lytes, maintenance fluids

mild dehydration percent weight loss

<5% infants

moderate dehydration percent weight loss

6-9% infants (6-8% child)

severe dehydration percent weight loss

>10% infants and child, signs and symptoms of shock

Diarrhea in infants and children

rotavirus, bacteria, protozoa, malabsorption, food allergy, response to meds, inflammatory bowel

causes dehydration!

meds to question with viral infections and diarrhea

you want them to poop! so don't give imodium, flagyl (for bacterial infections)

let time cure it!

home treatment of mild dehydration

ORT/ORS, (oral rehydration therapy/solution), has sugar and lytes, Powerade is not a substitute!

small frequent drinks, 2-5ml q2-3 mins, syringe or med cups, emesis -> wait 10 mins

cleft palate/lip

happens before most women know they are even pregnant, congenital abnormality due to the failure of closure of certain facial parts during embryonic development

cleft palate/lip cause

genetic link, environmental (smoking, etoh, infections), meds (dilantin, retin A, steroids), low folate

Retin A

causes a lot of birth defects, dont give to women of child bearing age

cleft lip problems for infant

feeding difficulties (cant form suction), weight gain is difficult, risk for aspiration, nasal deformity, dental abnormalities, speech, social acceptance

special nipples for cleft lip

squeeze bottle: ross nipple, mead-johnson

nipple hole/valve: pigeon, haberman, special needs feeder

cleft lip treatment

surgery at 2-3 months, z plasty / cheiloplasty

arm restraints for cleft lip

medical restraint to prevent playing with lips

cleft palate problems for infant

feeding difficulties (weight loss risk for aspiration), ear infections increased risk (can decrease hearing, lead to speech problems), possible dental work, social acceptance

cleft palate treatment

nutrition, possible prep for reconstruction, surgery at 6-12 months -> palatoplasty

cleft palate feeding

use of a cup after surgery! no sucking, 10-15ml water chaser

before dischagre with cleft lip and palate

have to show that parents are able to feed them and they are feeding well by diaper wights and input

Hirschsprung's disease

absence at birth of the autonomic ganglia in a segment of the intestinal smooth muscle wall that normally stimulates peristalsis

ribbon-like stools, reluctance to pass meconium, back up of stool causing impaction, rectum empty of stool, can lead to cdiff

malnourished growth chart

loose weight first, then stop gaining height, then stop growing head circumference

(bodyweight lowest, height low, head circumference normal-ish)

Hirschsprung's disease possible tests

H&H, albumin, total protein, x-ray, barium enema, biopsy, anorectal manometry

Hirschsprung's disease opportunistic pathogen

high risk for C-Diff

Hirschsprung's disease treatment

colostomy, normal saline enama till clear then antibitoic enema, golytely

intussusception

telescoping of a segment of the small intestine into the large intestine, most common cause of intestinal obstruction in toddlers

intussusception symptoms early

soft abdomen, intermittent colickly pain, normal stool, periods of no apparent distress

intussusception symptoms late

abd distended & firm, sausage shaped mass in RUQ, severe paroxysmal abd pain, currant-jelly stool, vomiting bile, dehydration -> shock

intussusception labs and tests

x-ray and ultrasound showing "target" and "crescent"

intussusception treatment

air enama or hydrostatic reduction

laparoscopic surgery

10% reduce on own without intervention

pushes small intestine out of large intestine

intussusception - when should hydrostatic reduction not be done

if there is a risk of perforation normally due to peritonitits

pyloric stenosis

narrowing of the opening of the stomach to the duodenum

Bile in the emesis suggests

not a pyloric stenosis

pyloric stenosis s/s

gradual onset, emesis or projectile emesis, no bile in emesis but blood possible, hungry after emesis, RUQ olive size mass, dehydration, metabolic alkalosis

pyloric stenosis treatment

rehydrate and stabilize lytes, pyloromyotomy

pyloric stenosis labs

metabolic alkalosis

pyloric stenosis postop nutrition

clear liquids -> full strength

slowly increase amount

usually full by 48 hours

GER/GERD will be on exam

Emesis, failure to thrive, esophagitis -> pin, gastric irritation -> anemia, aspiration pneumonia, apnea

cystic fibrosis

autosomal recessive genetic disorder, body makes too much mucus and salt, respiratory, GI, reproductive

sweat chloride test (need to know)

gold standard test for cystic fibrosis, at least 3 months old

neg <30,

diagnostic >60

cystic fibrosis treatment in order

exercise, albuterol, then percussion, then flutter device

pulmozyme (dnase)

nebulizer that works directly on mucus

tobramycin

nebulizer giving in cycles so child doesn't build immunity to medication

vaccines for cystic fibrosis

PPV (pneumococcal-23) and annual flu shot + all others

pancrease

check poop, if looking normal than have enough drug, if abnormal add more drug

Cystic fibrosis fat soluable

risk for not absorbing fat soluble things, supplement with A D E K vitamins

cystic fibrosis and meconium

1st sign of CF = not passing meconium in 24 hours

- when it comes out will be thick, sticky and small

- passing first meconium leads to rectal prolapse

cystic fibrosis diet

3 meals + 3 snacks a day, high calorie protein and fat diet, lots of salt

supplement with ADEK Iron Ca

Cystic fibrosis and oxygen

think like they have COPD, NC, mask if necessary, lower O2 rate better, 92-94% SaO2

cystic fibrosis signs

clubbing of nails, barrel chest, oral polyps, cracking of lungs, retractions, thick green blood tinged sputum, JVD, palpateable liver

cleanout for cystic fibrosis

No roommate, continue GI treatments, IV acess, cultured, antibiotics, oxygen, cultures, Frequent respiratory checks

What parts of the history are significant? Explain.

1) Respiratory – frequent infections

2) GI – delayed passage of meconium, malnourished, failure to thrive

3) Progression - worsening

What parts of the physical exam are significant? Explain.

1) Respiratory – crackles, wheezing, green mucus, CHF

2) GI – poor weight gain, failure to thrive,

3) Reproductive – delayed growth

The following labs and diagnostics ordered for Fred, and what do you expect the findings to be? (normal, increased, decreased

1) WBC - elevated

2) RBC, Hemoglobin & Hematocrit - low

3) Electrolytes – sodium if not supplemented, normal if supplemented

4) BUN, Creatinine – creatinine normal, BUN elevated (dehydration)

5) Chest Xray – stuff in xray

When you prepare to initiate oxygen when Fred (cystic fibrosis) is admitted to the Peds unit, which are you more likely to use, a nasal cannula or a non-rebreather mask? Explain.

nasal cannula, need to be able to expel sputum, 2-4L, don't want to stop breathing drive

What are your nursing actions at admission for cystic fibrosis? Prioritize your assessments and completion of orders that would be completed during the admission process.

after assessment; oxygen, albuterol, iv access, blood culture, start antibiotics

If the nurse manager was trying to assign a roommate for a new admission, postop tonsillectomy, would Fred (cystic fibrosis) be a good choice for a roommate (consider gender, possible infection, and age)? Explain

No, cystic fibrosis should not have roommate

Roomates

Determine gender if both children are > 2 YO, infection risk - prone to get, prone to give, Age (only if 2 roomates are available)

Give an example of foods that would follow the recommended diet for cystic fibrosis

high fat high protein high calorie

What medication must be given with the food cystic fibrosis

enzyme, with snacks also

cystic fibrosis, Long term, how will you know if the GI/Nutrition treatments are effective (expected findings)?

poop sinks

How will you know if the Respiratory treatments are effective (expected findings) cystic fibrosis

Os sat improves, pulse and resp decrease, temp decrease

Fred (cystic fibrosis) puts his call light on. When you enter the room, Fred appears to be in acute respiratory distress. Oximeter has dropped suddenly to 82%. He is diaphoretic with no lung sounds on the right side. What are your concerns and what do you do?

pneumothorax

How would you organize your care for Fred’s day shift? Include all meds, treatments and therapies (including Pancrease, Albuterol & Pulmozyme).

vitals, assessment, gentamycin IV

albuterol, pulmozyyme, chest PT, then tobramycin neb

weight

breakfast, pancrease, vitamins

snack, pancrease

bath/shower, linen change

vitals assessment, albuteral/chest PT,

lunch, pancrease

ceftazidime IV

snack, pancrease