pvcc pediatrics exam 2

barbara moris test plan for exam 2

DM T1

• Autoimmune condition resulting in pancreatic damage and lack of insulin. 

• Diagnose with laboratory testing: hemoglobin A1C

 fasting glucose

 plasma glucose

• Manifestations: weight loss, polydipsia, polyphagia, polyuria, fatigue, blurred vision, and mood changes

• Management is multifaceted and includes: Insulin therapy, Glucose monitoring, Insulin education, Maintaining proper nutrition, Patient and family education.

Dehydration

• Classified by severity: mild (3%–5% volume loss), moderate (6%–9% volume loss), or severe (≥10% volume loss) based on previous weight

• Calculating dehydration:

  

• Treat with a bolus of  20ml/kg bolus of NS over 30-60 minutes moderate-severe dehydration cases may require up to 3 boluses of 20mL/kg isotonic fluids before initiating maintenance fluids.

  • Reassess cues of dehydration after bolus to determine in another is necessary or start maintenance IVF with electrolyte replacement

NS bolus

Treat with a bolus of  20ml/kg bolus of NS over 30-60 minutes moderate-severe dehydration cases may require up to 3 boluses of 20mL/kg isotonic fluids before initiating maintenance fluids.

Maintenance IVF

• Done after rehydration

hydrocephalus

• Build-up of CSF in the brain due to increased CSF production and decreased CSF absorption

• Mx: depend on age and severity: Dilated scalp veins, bulging fontanel, apnea, irritability, headaches, and vomiting

  • Posterior fontanelles (smaller): closes 2-3 months

  • Anterior fontanelles (larger): closes between 12-18 months

• Tx: Ventriculoperitoneal shunt placement. May need replacement throughout lifetime as child grows. Monitor head circumference to assess patency. 

UTI

Pts at risk pre- and post- hypo&epispadis, during potty training,

Hypospadias

• The urethral opening is on the ventral side of the penis

• Avoid circumcision because that skin will be used for surgical correction

• Surgical correction produces the ability to urinate in the standing position, preserve physical appearance, maintain sexual function

  • Urinary diversion device may be placed for 5-10 days post-op

• Discharge Edu.: Pain relief including Bladder spasms, Bowel care regimen, Reduce risk for infection, No straddle toys

Encopresis

• defined as voluntary or involuntary passage of stool into inappropriate places at least once a month for 3 consecutive months after the age of 4 years. 2 types: 

  • retentive encopresis: history of chronic constipation, most common form: 65%–95% of children

  • Parents may see liquid stools in underwear (why?)

• Non-retentive encopresis is when constipation is not present

• Can be associated with emotional or psychological disturbances

hypothyroidism

• Insufficient thyroid hormone 

• Manifestations: low T3 and T4, persistent open posterior fontanel, thickened protuberant tongue, dull expression, hypotonia, etc

• Treat with sodium levothyroxine (a synthetic thyroid hormone) and frequently monitor levels, track and trend growth 

  

Intussusception

• The intestine pushes into itself.

• Most common cause of obstruction in 5 months to 3yrs old

• Abrupt onset of severe, paroxysmal, and colicky pain.

• Currant jelly (red) stools and nausea and vomiting.

• Enemas given under imaging to reduce the defect.

• Surgery needed if enema is not effective.

  

congenital clubfoot

• More common in boys, can unilateral or bilateral

• Heel tilts in and down, forefoot turns in, and bottom of the foot faces inward or upward. Shorter Achilles tendon and foot and calf on affected side.

• 2 step treatment: 1rst serial casting with long leg casts changed weekly (begin early before bones ossify), then Bracing for 2 to 4 years afterward to maintain correction

bronchiolitis

• Respiratory syncytial virus (RSV)

• Cells in bronchioles die and accumulate and obstruct.

• Mild cough, rhinorrhea, and congestion

• Worsening symptoms after 2 days

• Symptomatic treatment; self-limiting suction before bedtime and feedings, encourage fluids 

Respiratory Failure

• Leads to cardiopulmonary arrest if untreated.

• Quickly determine cause to choose appropriate interventions.

• Manifestations: respiratory rate changes (tachypnea, apnea, or bradypnea), shallow chest rise, altered mental status, and cyanosis.

• Tx: open airway, use BVM until intubation can be done

• Encourage parents to be present during resuscitation efforts

Hypovolemic shock

Sickle Cell Anemia

• Mutation of Hgb causes the body to create “sickled” or “C – shaped” red blood cells that are sticky and have crystals attached. These abnormal cells do not have the same oxygen-carrying capacity as normal hemoglobin and die in 17 days 

• Pts will typically be asymptomatic until a vasoactive crisis occurs

• Seen across the malaria belt 

SSA Medications

• Prevention: folic acid, iron chelators, penicillin, hydroxyurea

  • Penicillin is given daily to help reduce risk of infection

  • Hydroxyurea: helps to prevent crisis but can cause liver damage and immunosuppression due to it being a chemo drug. 

• Opioids: oxycodone, morphine, hydromorphone, narcan

  • Narcan at a low rate 0.5-1.5mg/kg w/ a concentration of 8 mcg/ml stops side effects of opioids like itching, respiratory depression, urine retention, without taking away pain relief

• NSAIDs: Ibuprofen, tylenol, ketoralac

• Misc. Meds: methadone, ketamine, blood transfusion 

SSA Complications

• Sickle Cell Crisis:  occurs when sticky cells create occlusion in blood vessel, preventing oxygenation of the tissues this leads to pain, organ and bone damage, increased morbidity and mortality

• 

• Other complications include delayed growth, lack of milestones reached, cognitive/social delays, Failure to thrive or obesity

• 

SSA Emergencies

SSA Nursing Care

SSA Triggers

Cast Care

• Handle a wet cast with open palms.

• Elevate the cast above the level of the heart and ice to prevent swelling.

• Assess for bleeding if applied postoperatively.

• Assess for signs of infection (i.e., foul odor, drainage, fever, warmth, and redness).

• Assess for skin breakdown and pressure points.

• Keep the cast clean and dry.

• Never put anything inside the cast – use cool setting on blow dryer for itching.

• Prepare patients and caregivers before cast removal.

• 

Nephrotic Syndrome

• Tx: prednisone, cyclophosphamide, tacrolimus, furosemide, enalapril

  A group of symptoms that indicate kidney damage and results in too much protein from the body in the urine 

• S/Sx: periorbital, facial, pitting, edema distended abdomen

VP (ventriculoperitoneal) shunt

Used to drain hydrocephalus

Duchenne Muscular Dystrophy

• X-linked genetic disease characterized by muscle wasting and progressive muscle weakness due to muscle fiber degeneration progression and onset vary but disease is fatal

• Early diagnosis and therapy is essential, glucocorticoids can delay loss of ambulation, prevent scoliosis, and preserve lung function but cause osteoporosis and nutritional deficiencies.

• Dystrophin deficiency leads to pulmonary compromise and a weak myocardium (medications can improve cardiac function).

  

Shaken Baby Syndrome

#1 cause of brain damage in infants

can either be a Suspected Non-Accidental Trauma or deemed intentional or non intention

the force exerted on shaking can cause cerebral edema, hemorrhage, hydrocephalus, and retinal hemorrhage

survivors usually have permanent disabilities

Cues include vomiting, irritability, increased sleeping, seizures and apnea.

cleft lip

• Tissues in lip and/or palate do not fuse. Resulting after feeding, ontological, dental, and speech complications.

  • Primary focus is nutrition and hydration

  • Prevent aspiration and infection

• Surgical repair (lip: 2-6 months; palate: 9-18 months).

• Protect suture line post-operatively.

• Requires specialized feeding equipment.

Fractures

• Fractures in the growth plate have higher risk for deformity and impaired healing

• Tx: Immobilize with splints, casts, or traction, Reduce the fracture (put the bone back into place) and immobilize to allow for healing

• Provide infection control to avoid osteomyelitis

• Mx: swelling, pain, obvious deformities, abnormal positioning, and inability to bear weight or move affected area

Blount Disease

• Aka Tibia Vera or Bowed legged

• Tibia growth plate grow inward, suspected if still present past the age of 3

• Tx: bracing if younger than 4 years old, surgical treatment can be done if bracing is ineffective, may have cast or external frames post-op

• Those who receive surgery will have increased risk of compartment syndrome, and DVT post op

• Provide Psych support for parents and child

ICP

• Developmental (primitive) reflexes present at birth and are replaced by protective reflexes over first year of life.

osteogenesis Imperfecta

• Collagen disorder resulting in fragile bones 

  • Collagen: Protein of the body’s connective tissue that bones are formed around.

• Tx is palliative in nature

• Avoid automatic blood pressure cuffs and rough handling, which can cause fractures.

• Provide growth hormones and bisphosphonates for bone growth

Tumor Lysis Syndrome

• will result in hyperkalemia (Tx calcium gluconate, followed by insulin & dextrose), hyperphosphatemia (tx phosphate binder), hypocalcemia (will correct when phosphate levels drop), and hyperuricemia (Tx: allopurinol)

• Metabolic abnormalities from release of intracellular content offer malignant cells are destroyed. Hydrate pt w/ IV fluids prior to chemo

• Treat with allopurinol prophylactically - prevents uric acid from being made, can cause the need for dialysis

• S/Sx: hyperkalemia, hyperphosphatemia, hypocalcemia (look for tetany), hyperuricemia (can cause kidney stones, HYDRATE!)

Leukemia

2 types: ACUTE LYMPHOBLASTIC LEUKEMIA (ALL), ACUTE MYELOGENOUS LEUKEMIA (AML)

ALL

• is the most common form of cancer in US children in which immature, nonfunctioning WBCs (lymphoblast) dominate bone marrow production

• Takes alot of different drugs to treat

• S/Sx: fatigue, pallor, fever, anorexia, petechiae

• Tx: chemo in 3 phases: 

  • Induction - 4 wk course will induce remission

  • Consolidation - strengthens remission & CNS prophylaxis w/ intrathecal chemo

  • Petechiae - 2-3 yrs eliminated residual cancer cells w/ intermittent chemo 

Acute Myelogenous Leukemia

• Doesn’t respond to treatment as well ALL, will require shorter more intense treatment. Many require bone marrow or stem cell to survive

Compartment Syndrome

• Swelling and pressure inside the muscle can impair circulation and cause necrosis

• Assess peripheral pulse, and oxygenation/perfusion to any casted area routinely

• A medical emergency, must relieve the pressure in the compartment 

Acetaminophen

• reduces fever and pain

• 10-15 mg/kg every 4-6 hours 

• Do not exceed 4,000 mg/d

• Metabolized by liver, can be hepatotoxic 

cefepime

Broad spectrum antibiotic

Desmopressin

Intranasal desmopressin is a treatment for hemophilia

Hydroxyurea

• Increases the level of fetal hemoglobin and helps to prevent sickle cell crisis

• Promotes splenic function

• Can cause neutropenia so monitor CBC and fHgb

oxygen

• Nasal cannula (0.1-6 L/min (infants are smaller so they may only need 0.1-0.25 L/min of O2) 

• Simple mask (5-10 L/min)

• Non-rebreather mask (10-15 5L/min)

• BiPAP, CPA

lead poisoning

Tx: Chelation therapy, poison control