Test 2 - GIGU

________ in girls promotes risk for infection. ​

shorter urethra

________ , kidneys less efficient at regulating fluid & electrolyte and acid/base balance

slower GFR

• Smaller bladder capacity (_____ cc in infants vs. 700 cc in adults)

20-50 cc

Urine output should be ~__ mL/kg/hr in infants,

between _____ mL/kg/hr in older children ​

2, 0.5-1

Renal system reaches maturity at _ years

2

•Infection of the urinary tract, most commonly the bladder, from bacterial transmission via the urethra ​

•Females at increased risk d/t shorter urethra length & proximity of urethra to vagina & anus

UTI

irritability, fever, poor feeding, vomiting, jaundice ​

UTI in infants

fever, vomiting, dysuria, incontinence, urinary hesitancy and urgency, hematuria, abdominal pain, flank pain, foul-smelling urine ​

UTI in children

if left untreated UTI can lead to

pyelonephritis, urosepsis, renal scarring, hydronephrosis ​

what will the analysis for a UTI show

Positive for blood, nitrites, leukocyte esterase, white blood cells, or bacteria;

culture will reveal infecting organism ​

true or false UTI can present as just a fever

true

nursing care for a UTI

most managed at home

ensure adequate hydration

Avoid urinary retention, frequent bathroom breaks (note for school-aged child)

UTI females prevention

no bubble baths or soap application to the vulva, wipe front to back, cotton underwear, change pads/tampons frequently during menstruation, void after intercourse

how to make sure the UTI is gone

Complete full ABX course and return to PCP for re-check ​

Pain management & antipyretics for UTI

acetaminophen, ibuprofen, small children may void in warm bath, heating pad

Hospital admission criteria & care for UTI

infant <2 months,

s/sx urosepsis,

immunocompromised patient,

inability to tolerate oral medications ​

care for UTI

administer ABX therapy,

hydrate via oral or IV fluids,

pain management & antipyretics PRN ​

the urethral opening is located on the ventral side of the penis

hypospadias

the urethral opening is located on the dorsal side of the penis

epispadias

backing up of urine into the kidneys (which get enlarged) ​

Vesicoureteral reflux ​

a congenital anomaly of the male urethra, foreskin, and penis leading to the abnormal ventral placement of the urethral opening ​

hypospadias

defect in which the urethral opening is on the dorsal surface of the penis​

•Abnormal displacement has the potential to cause developmental or functional issues:​

Epispadias

what are the functional issues of epispadias

- Deflection of urinary stream ​

•Inability to urinate standing ​

•Erectile dysfunction causing intercourse difficulties ​

•Problems with fertility given altered deposition of sperm​

•Circumcision is contraindicated before surgical repair

for nursing care for epi and hypo spadias

Surgical repair occurs around to _ months of age and is usually outpatient ​

6 to 12

for nursing care for epi and hypo spadias

medication administration-

analgesics (acetaminophen, ibuprofen) & antispasmodics (oxybutynin)​

•Antibiotics are given postop to prevent infection while catheter is in place​

for nursing care for epi and hypo spadias

site care

•Surgical site care (dressing stays in place ~3 days, soak off, may apply Vaseline to outer diaper once dressing comes off)​

•Double-diapering & catheter care

•When to call the provider or go to ED for epi and hypo spadias

Fever, excessive bleeding, inconsolable pain, change in urine output

Retrograde passage of urine from the bladder into the upper urinary tract can cause renal scarring; potential for renal insufficiency or failure later in life​

Vesicoureteral reflex

congenital abnormality, inadequate closure of ureterovesical junction is a failure of the anti-reflex mechanism ​

primary Vesicoureteral reflex

result of high pressure in the bladder à failure of ureterovesical junction closure; may be caused by neurogenic bladder, obstruction, or dysfunction of the bladder​

secondary Vesicoureteral reflex

Vesicoureteral reflex diagnosed by

voiding cystourethrogram (VCUG) (see how urine flows as they urinate)​

severity of Vesicoureteral reflex is graded on scale of

•Grades III-V associated with​

I-V,

recurrent UTIs, hydronephrosis and renal injury ​

Vesicoureteral reflex :Nursing care

Daily administration of ________ _______ until VUR is resolved (spontaneously or surgically) ​

•Educate child and caregiver about proper toileting & perineal hygiene, the need for ____ ______ ___ and ______

prophylactic antibiotics, regular urine testing, VCUGs

Vesicoureteral reflex :Nursing care

Postoperative care

IVFs 1.5 maintenance rate to promote urinary output​

•Strict I &O​

• Foley and stents may be in place; urine will be bloody for 2-3 postop ​

•Administer analgesics & antispasmodics​

Ambulate, advance diet as tolerated

what are acquired urinary disorders

nephrotic syndrome,

post-streptococcal glomerulonephritis,

hemolytic uremic syndrome

Increased permeability across the glomerular filtration barrier a passage of plasma proteins through basement membrane a loss of protein in urine & decreased protein and albumin in serum​

•Hypoalbuminemia is a change in osmotic pressure that fluid shifts into interstitial tissue, shift in volume prompts kidneys to conserve water and Na which causes edema

nephrotic syndrome

nephrotic syndrome in the absence of disease, includes idiopathic, which is the most common form (~90% of patients)

primary nephrotic syndrome

nephrotic syndrome associated with systemic diseases or is secondary to another process that causes glomerular injury (ex- HUS, Systemic Lupus Erythematosus Henoch-Schönlein Purpura, Sickle Cell disease, infective endocarditis) ​

secondary nephrotic syndrome

S/sx include: Nephrotic syndrome ​

•Nephrotic range proteinuria – Urinary protein excretion greater than 50 mg/kg per day​

•Hypoalbuminemia – Serum albumin concentration less than 3 g/dL (30 g/L)​

•Edema (generalized – anasarca) ​

•Hyperlipidemia

Nephrotic syndrome :Nursing care

Promote _____​

•Administer _______ (prednisone) and _____ (furosemide) as ordered ​

•___ weights​

•Monitor ____ and _____​

•Regular assessment of VS and edema ​

•Administer ____ as ordered for severe hypoalbuminemia​

•Prevent infection​

•Give prophylactic ABX as ordered ​

diuresis, corticosteroids, and diuretics, daily, UOP and proteinuria, albumin

Vaccine administration for nephrotic syndrome

pneumococcal & varicella, avoid live vaccines during steroid treatment ​

nutrition for nephrotic syndrome

•May require fluid and salt restriction ​

•Encourage foods high in protein and potassium (if low from diuretics)

teaching for nephrotic syndrome

teach how to check for proteinuria

•Immune complex disease that occurs after an infection. ​

•Infection immunologic response, immune complexes deposit into glomerular membrane glomerular inflammation and injury, can lead to uremia and renal failure

Post-streptococcal glomerulonephritis ​

Recent infection (viral URI, strep),

fatigue,

hematuria,

proteinuria,

decreased glomerular filtration rate, GFR

and retention of sodium and water causes edema & HTN

Post-streptococcal glomerulonephritis ​

Nursing care (supportive) - for Post-streptococcal glomerulonephritis ​

•____ therapy if strep infection is present ​

•Monitor and manage HTN with _____ (ex-labetalol) & _____ ​

•____ weights​

•Na and water ____ ​

•Strict I&O​

•____ care to allow for rest ​

•May require _____ for life-threatening fluid overload refractory to treatment, uremia, elevated K+ resistant to treatment

ABX, antihypertensives and diuretics, daily, restriction, cluster, dialysis

•Three defining features of Hemolytic Uremic Syndrome - HUS

Hemolytic anemia,

thrombocytopenia,

acute renal failure

acquired HUS includes

Shiga toxin-producing E. coli (90% of peds cases)

E. coli 0157 transmitted via undercooked beef, feces of certain animals, unpasteurized dairy

abdominal pain, vomiting, diarrhea (usually bloody), hematuria;

s/sx begin 5-10 days after diarrhea onset

HUS

Streptococcus pneumoniae 5%-15% of pediatric HUS cases ​

•Develops following ______ infection​

•_______ vaccine is protective against many strains

pneumococcal

pneumonia, usually with empyema or effusion, dyspnea, respiratory distress, fever, cough ​

•Patients may progress to severe AKI or renal failure; ~50% of patients will need dialysis ​

•Neurologic s/sx may be seen in up to 20% of patients- altered mental status, seizures, coma, stroke

Streptococcus pneumoniae HUS

HUS nursing care

•Care is _____ ​

•______ ​

•Slow infusion of ______ (for Hgb <6) over ___ hours to prevent fluid overload ​

•__________​

•PLT transfusion only if significant ______ present ​

•Maintain appropriate fluid balance

supportive, PRBC, 3-4, thrombocytopenia, bleeding

Tricky as patients with HUS may have increased (from oliguria or anuria) or decreased (from vomiting, diarrhea, decreased intake) intravascular volume​

•If decreased intravascular volume- administer ____ to restore euvolemic state​

•If increased intravascular volume- administer ____ and ___________ as ordered ​

fluids, diuretics, antihypertensives

HUS - nursing care
Monitor _____ function, prevent further injury ​

•Labs- ________​

•Avoid administration of _____ medications ​

•Manage ____ - restore euvolemia, administer diuretics or antihypertensives as ordered ​

•Education should be given surrounding risk of transmission (STEC is shed for ~__ days, longer in younger patients ~__ weeks)​

kidney,

CBC, creatinine, BUN, electrolytes,

nephrotoxic,

HTN,

7, 3

Upper GI Tract​

•Lower esophageal sphincter is fully developed at __ month of age – why babies spit a lot​

•Stomach capacity in infancy is ~___ mL (adult 2,000-3,000 mL, gastric emptying faster than in adults

1, 200

Lower GI Tract​

•Small intestine is ~___ cm vs 600 cm in adults ​

•Healthy infants have a ____ intestinal transit time than adults ​

•Liver is ~___ size of the abdominal cavity, edge may be palpable on exam 2-4 cm below the right costal margin ​

•Immature neuromuscular function, often stool after eating as a result of the gastrocolic reflux by ~____ voluntary control of BMs occurs ​

•_______ is first stool and appears black in color, sticky ​

200, faster, 1/2 , 2, meconium

Passage of gastric contents into the esophagus (regurgitation or ‘spitting up’) ​

•Frequent in infants <12 months (~30x/day) ​

Gastroesophageal reflux

S/sx may be vague and include

poor weight gain (FTT),

feeding refusal,

irritability,

respiratory symptoms (cough, wheezing),

neck or back arching, heme + stools​

GERD

before diagnosis of GERD, what must be ruled out

underlying causes like food allergy, malrotation, and neurologic impairment

Conditions associated with GERD-

obesity,

CF,

neurologic impairment,

prematurity,

hiatal hernia,

achalasia

GERD- Nursing Care

Administering feedings ​

•Elevating head or head of bed​

•Keep infant upright for at least 30 minutes after feedings ​

•Smaller, more frequent feedings; avoid overfeeding ​

•Thicken feeds (oat cereal) ​

GERD should resolve _____ as the infant grows; however, with moderate to severe cases, infants may require medication

(___ Omeprazole, __________- Famotidine) ​

•______ ______ reserved for infants with severe GERD, refractory to the above treatment

spontaneously, PPI, H2 receptor antagonist

Nissen fundoplication

Congenital anomaly caused by a defect in the lateral septation of the foregut into the esophagus and trachea;

trachea & esophagus do not separate normally during development

Esophageal Atresia & Tracheoesophageal Fistula (EA/TEF)

Clinical presentation of TEF depends upon the presence or absence of ___

EA

proximal & distal ends of the esophagus do not communicate (blind pouch)​

EA

S/sx present after birth-

drooling, choking, coughing, cyanosis, respiratory distress, inability to feed (aspiration), NGT coiled in esophagus (cannot pass), abdominal distention ​

Esophageal Atresia & Tracheoesophageal Fistula (EA/TEF)

Esophageal Atresia & Tracheoesophageal Fistula (EA/TEF) 50% of cases have associated anomalies

VACTERL association or CHARGE syndrome

dx of Esophageal Atresia & Tracheoesophageal Fistula (EA/TEF)​

chest x ray, UGI series

TEF/EA- Nursing Care​

Preoperative care​

•NPO, NGT/OGT to ___ _______ _____ ​

•Administration of _________ _______, _____ – have to make them NPO​

•PRN suctioning & oxygen ​

•Comfort measures ​

•Caregiver education

low continuous suction, parenteral nutrition, IVFs,

TEF/EA- Nursing Care

Postoperative care

Routine postop care ​

•Administer __________, ____ ___​

•Transport to radiology for ____ to assess the patency of the esophageal anastomosis ​

•Administer PO feeds when ordered ​

•Caregiver support & education, s/sx when to call provider, PPI administration, possibility of need for future esophageal dilations ​

parenteral nutrition, IV ABX, UGI

Most common congenital craniofacial abnormality, ~30% associated with genetic syndromes ​

•Infants are at higher risk of developing if the mother _____, takes certain _____ , or is considered _____ __ ___

cleft lip palate,

smokes, medications, advanced in age

for cleft lip/palate

Lip is repaired at __ months & palate at _ months of age

3 and 6

Cleft Lip & Palate- Nursing Care ​

•Promote Nutrition​

•If cleft palate is present, infant may not be able to generate enough pressure to suck milk from bottle or breast; adaptive equipment may be used to assist in feedings (__________) ​

•If cleft lip alone is present, infant can feed from _______​

•Increased risk for _______ with cleft palate, covering of palate with a __________ should be used for prevention

squeezable bottle or modified nipple

bottle or breast

aspiration, prosthodontic device

Cleft Lip & Palate- Nursing Care

Parents may experience distress surrounding infant appearance & hospitalization ​

•Support parents in providing feedings and other care to infant​

•Provide education for anticipated surgeries

encourage infant-parent bonding

Cleft Lip & Palate- Nursing Care = Postoperative Care​

•Pain management with medications and comfort measures (holding, rocking, singing), anticipate needs ​

•Prevent damage to suture lines of lip and/or palate (infant should lay ____ , may require _____ or welcome-sleeve restraints)​

•Do not allow the infant to ____ on a pacifier, plastic syringe, or straws in older children undergoing repair ​

•No ___ ______(or minimum)​

​

supine, mittens, suck, oral suctioning

Destruction of enterocytes is a shift of fluid into intestinal lumen and there is a loss of fluid & salt in stool (diarrhea)​

•Intestinal injury decreases digestion & absorption​

•Occurs in infants & children year-round ​

•Transmitted most often by fecal-oral route by symptomatic & asymptomatic carriers ​

Acute Viral Gastroenteritis

infectious pathogens of Acute Viral Gastroenteritis

rotavirus, norovirus, enteric adenovirus ​

•Symptomatic onset dependent on the virus (incubation period differs) ​

diarrhea, vomiting, or both; other s/sx may include fever, abdominal pain, myalgia, anorexia ​

acute viral gastroenteritis

Patients with moderate to severe disease

- weight loss, electrolyte disarray,

tachycardia, hypotension,

sunken fontanelle,

dry mucous membranes, reduced skin turgor,

low UOP, listlessness, lethargy

acute viral gastroenteritis

Acute Viral Gastroenteritis: Nursing care

Treatment is _________ : ​

•__________ & replacement of ongoing fluid losses​

•Mild to moderate:

•Moderate to severe: ​

•Antiemetic medications ​

•Diet- ________ are preferred; avoid fatty or sugary foods (BRAT diet not necessary, bananas, rice, applesauce, toast) ​​

supportive,

fluid repletion,

Oral rehydration therapy (ORT),

IV hydration,

(Zofran),

complex carbs

Acute Viral Gastroenteritis: Nursing care

Caregiver education: _______ may last several days after discharge home, handwashing, s/sx when to call provider or return to ED ​

• ______ vaccine* ​​

diarrhea, rotavirus

Hypertrophy of the pylorus, causing an obstruction of the gastric outlet, often causing projectile vomiting ​

Infantile Hypertrophic Pyloric Stenosis

Infantile Hypertrophic Pyloric Stenosis

Occurs early in infancy between ~____ weeks ​

•Vomiting occurs immediately _____ feeding​

•Infants are ___________, wanting to be fed again soon after emesis

3-6, following, irritable and hungry

s/sx -

failure to gain weight or weight loss,

dehydration (dry mucous membranes, no tears),

hypochloremic metabolic alkalosis,

palpation of ‘olive-sized’ mass in RUQ ​

Infantile Hypertrophic Pyloric Stenosis

dx of Infantile Hypertrophic Pyloric Stenosis

Abdominal US will demonstrate hypertrophied pylorus ​

Hypertrophic Pyloric Stenosis- Nursing Care​

treatment is surgical -

laparoscopic pyloromyotomy

Hypertrophic Pyloric Stenosis

Preoperative​

•Administer ____ to correct dehydration & electrolyte disturbances​

_______ (x1 or x2, depending on the degree of dehydration and hypochloremia) ​

______ at 1.5-2x maintenance rate ​

•NPO before surgery ​

•Education & support to caregivers surrounding surgery

IVFs, bolus of NS, MIVFs

Hypertrophic Pyloric Stenosis

Postoperative ​

•Resume oral feeds and continue IVFs until tolerating PO ​

•Strict I&Os ​

•Monitor surgical site

• Most common cause of intestinal obstruction in children 6 months to 3 years of age ​

• Bowel telescopes into a distal portion of itself, if left untreated, it can cause edema, vascular compromise, and bowel obstruction ​

• Classified by location

Intussusception

90 of Intussusception

ileocolic

Intussusception may be preceded by

most are caused by ______

viral illness (URI, AOM), idiopathic

sudden, crampy, intermittent abdominal pain; severe abdominal pain, child may draw knees to chest, vomiting, diarrhea, lethargy, currant-jelly stools*, sausage-shaped mass on abdominal palpation ​

Intussusception

Intussusception- Nursing Care​

•Stable child without s/sx perforation

Administer IVFs ​

•Transport to radiology for air (pneumatic) or contrast (hydrostatic) enema​

•Educate caregivers surrounding procedure and likelihood of recurrence (~50% reoccur in first 72 hours following nonoperative reduction)

Intussusception- Nursing Care

Ill-appearing child, s/sx bowel perforation, or nonoperative intervention unsuccessful

Emergent surgical intervention (diagnostic laparoscopy and/or exploratory laparotomy) ​

•Administer IVFs and ABX

NGT decompression ​

•Post-op care- important to assess for s/sx recurrence (occurs in up to 20% of patients)​

•Caregiver support & education (likely to reoccur)

Neural crest cells fail to migrate completely during intestinal development of the aganglionic segment of colon that lacks the abilty to propel intestinal contents (functional obstruction)​

Hirschsprung Disease

Hirschsprung Disease

Aganglionic segment may be short (rectosigmoid),

long (extends proximal to sigmoid colon) and total colonic aganglionosis ​

•Outcomes worse with _________ disease ​

•Associated with ____________ (ex- trisomy 21)​

long-segment

chromosomal anomalies

Hallmark is delay or failure to pass meconium in first 48 hours of life – unable to tolerate feeds​

Hirschsprung Disease

abdominal distention,

poor feeding,

constipation,

bilious emesis,

‘squirt’ or ‘blast’ sign ​​

Hirschsprung Disease

Bacterial overgrowth in bowel lumen from stool stasis, translocation of bacteria through mucosa

•Hirschsprung-associated enterocolitis (HAEC)

fever, vomiting, lethargy, abdominal pain, explosive and foul-smelling diarrhea ​​

Hirschsprung-associated enterocolitis (HAEC)