Maternity Exam 3

Cleft lip and palate

Cleft lip and palate

Occur from embryonic developmental failures resulting in an abnormal opening in the lip or palate. This may disrupt the ability to suction during feeding, putting child at risk for aspiration, respiratory distress and feeding difficulties

Interventions cleft lip

Modification of feeding techniques, repair of cleft, treatment of recurring otitis media, speech dysfunction, emotional issues

When will cleft lips be repaired by?

3-6 months

When will cleft palats be repaired by?

1 year or sooner

Esophageal atresia with tracheoesophageal fistula

Congenital malformation, the esophagus terminates before it reaches the stomach and/or a fistula is present that forms an unnatural connection between the esophagus and the trachea. If left untreated aspiration pneumonia, severe respiratory distress, and death may result

Three Cs of child with esophageal atresia

Choking, coughing, cyanosis

Therapeutic care of child with EA or TEF

Keep the infant supine with HOB elevated(anti-reflux position), NG tube to keep proximal pouch clear, surgical repair is the mainstay of treatment, G tube placement if staged repair is necessary

Gastrointestinal hernia

an abnormal protrusion of part of an organ or tissue through the structures that normally contain it

When is a hernia a medical emergency?

When the hernia becomes strangulated and requires immediate treatment

Hiatal hernia

Protrusion of a portion of the stomach through the esophageal hiatus(can be managed medically or surgically)

Congenital diaphragmatic hernia

Opening in the diaphragm through which abdominal contents herniate through the thoracic cavity

Imperforate anus

incomplete or absent anus

Gastroschisis

herniation of the intestines on one side of the umbilical cord, viscera are outside the abdominal cavity

Umbilical hernia

Imperfect closure of the umbilical ring

Omphalocele

Larger herniation of intestines into the umbilical cord

Gastroesophageal refluc disease

severe and chronic regurgitation of gastric contents into the esophagus(some reflux is normal in infancy, chronic recurrent reflux is indicative of GERD)

S+S of GERD

Vomiting or spitting up after meals, hiccuping and recurrent otitis media are the hallmarks of GERD

Physiologic gastric refluc(normal GER)

Painless emesis after meals, rarely occurs during sleep, no failure to thrive, parents may be unconcerned, can be asymptomatic

Pathologic reflux(GERD)

Failure to thrive, asperation pneumonia and/or asthma, apnea, coughing, choking, frequent emesis, abdominal pain, crying, may require surgery and pharmacologic treatment

Therapeutic management of GERD

Diet, positioning, medications, treatment of acute bleeding, surgery

Constipation

Delay or difficulty in defecation present for 2 weeks or more

Encopresis

Repeated, involuntary defecation in a child older than 4 years. Often a result of severe impacted stool

Therapeutic management constipation or encopresis

Disimpaction(critical), education on how to encourage elimination, maintenance, changing retention habit

How to change retention habit for constipation

Regular toilet times, behavioral chart with positive rewards, avoid negative reinforcement, increased physical exercise

Goal of management constipation

2-3 stools daily, without pain for 1 month

Infectious gastroenteritis

Viruses, bacteria, and parasites which cause serious communicable diarrhea, massive fluid and electrolyte loss, sepsis, and death.

How is Infectious gastroenteritis contracted

ingestion of contaminated food or water, person to person contamination. Common in daycare centers, preschools and childcare facilities

Pathogens that cause Infectious gastroenteritis

giardia, rotavirus

Therapeutic management Infectious gastroenteritis

Maintaining fluid balance, reduce exposure to other family members, pain management, education, maintain skin integrity

Appendicitis

Inflammation and infection of the appendix, most common cause of emergency surgery in children

Assessing appendicitis in the child

Symptoms develop slowly over a 12 hour period, child may lie down in a knee-chest position, greatest pain in right lower quadrant

S+S appendicitis

Pain, anorexia, nausea and vomiting and fever, if pain precedes vomiting appendicitis is most likely

Treatment uncomplicated appendicitis

Comfort measures, cold application, analgesia, IV fluid therapy, surgery

S+S ruptured appendex

sudden relief from pain followed by increase in pain, rigid abdomen, early shock

Surgical management after ruptured appendix

NG tube, IV antibiotics, analgesia, possible incisional drains, longer hospitalization

Inflammatory bowel disease

chronic inflammatory condition of the small or large intestine

Ulcerative colitis

Form of IBD that affects only the colon, involves mucosal and submucosal layers of the GI tract

Chron’s disease

Form of IBD that involves the entire GI tract, involves all layers of the intestine

Therapeutic management of IBD

Medication, dietary and nutritional support, symptomatic treatment

Hypertrophic pyloric stenosis

The circular area of muscle surrounding the pylorus hypertrophies and obstructs gastric emptying

Symptoms HPS

Progressive, projectile non-bilious vomiting, usually starting after 3 weeks of age in a previously healthy infant. Moveable palpable, olive shaped mass in RUQ, visible peristaltic waves

Intussusception

a section of the terminal ileum telescopes into the ascending colon through the ileocecal valve

Classic signs of intussusception

Abdominal pain, passage of bloody mucus, “current jelly” stool and diarrhea, sausage shaped abdominal mass

What can occur id intussusception obstruction is present for >12-24 hours

Shock and sepsis

Therapeutic management intussusception

if shock and sepsis is not present, isotonic saline, barium, or air enema under fluoroscopic or ultrasonic guidance will push bowel back into place. If no success, immediate surgery

Nursing Dx and planning intussusception

risk for ineffective tissue perfusion, acute pain, deficient fluid volume, deficient knowledge, anxiety, disturbed sleep pattern

Volvulus

malrotation or twisting of the bowel that results in a bowel obstruction

S+S volvulus

Pain, bilious vomiting, S+S bowel obstruction

Treatment volvulus

surgery is essential to prevent bowel obstruction

Hirschsprung disease

Absence of gangion cells in the rectu and upward in the colon, adequate peristalsis cannot occur. Major cause of bowel obstruction in newborns

S+S hirschsprung disease

delayed passage of meconium(>24 hours), constipation or infrequent stools in 1st month, pellet like or ribbon-like stools

Therapeutic management Hirschsprung disease

Treatment involved removing the aganglionic portion of the intestine in a one or two step surgical intervention. Temporary colostomy may be performed

Lactose intolerance

An absense of deficiency of the enzyme lactase. Inability to tolerate lactose, the sugar found in dairy products.

S+S lactose intolerance

Frothy diarrhea, abdominal distention, cramping, excessive flatus

treatment lactose intolerance

Lactose free diet, obtain calcium through other sources, such as egg yolks, green leafy veg, dried beans, cauliflower

Celiac disease

Inability to digest gluten, the protein found in wheat, barley, rye. Lifelong deficiency

S+S celiac disease

Diarrhea, growth failure(<25th percentile)

Celiac crisis

Profuse, water diarrhea and vomiting, severe dehydration, metabolic acidosis

Care of a child with celiac disease

Eliminate all gluten from diet permanently, use gluten free substitutes, supplement with vitamins for folate and fat-soluble vitamins.

Biliary atresia

Obstruction of absence of the extra-hepatic bile ducts. Liver appears normal at birth

S+S biliary atresia

Weeks into life infant develops jaundice, bile stained urine, hepatomegaly, increased abdominal growth, structural problems quickly lead to cellular damage, liver failure, and possible death

Treatment biliary atresia

Liver transplant

Genitourinary system differences in children

Kidneys operate at functional level appropriate for body size, reach full adult function at 6-12 months of age. Infants cannot concentrate urine as efficiently(why they cannot tolerate dehydration)

Enuresis

Difficulty in maintaining bladder control

Diurnal enuresis

Urgency, frequency, and inappropriate wetting during the day

Nocturnal enuresis

History of bed wetting, unable to sense a full bladder, should not be a concern until older than 6 years of age

Therapeutic management enuresis

Diagnostic evaluation, limiting fluids and altered diet, imagery, behavioral conditioning, setting alarms to go, desmopressin acetate, voiding frequently

Urinary tract infections cause

Caused by urinary stasis, anatomic differences, individual susceptibility to infections, urinary retention, bacterial colonization

Symptoms of UTIs in infants

Nonspecific, fever or hypothermia in neonate, irritability, dysuria as evidences as crying when voiding, change in urine odor or color, poor weight gain, feeding difficulties

Symptoms of UTIs in children

Abnormal or suprapubic pain, voiding frequently, voiding urgency, dysuria, new or increased incidence of enuresis, fever

Vesicoureteral reflux

Urine flows from bladder back into ureters, grading is based on degree of reflux into upper genitourinary tract structures, management is based on the grade of involvement. Reflux with infection is most common cause of pyelonephritis

Management and prevention of UTI

wipe from front to back, avoid holding urine, cotton underwear, avoid baths, good hygiene

Cryptorchidism

One or both testes fail to descend through the inguinial canal into scrotal sac, most will spontaneously resolve by 6 months

Risks unresolved cryptorchidism

increased risk of testicular malignancy and infertility

Treatment cryptorchidism

Surgical correction between 6-12 months is recommended

Hydrospadias

Urethral opening in males is below its normal location of the glans of the penis, higher irks for undescended testes

Epispadias

The urethral opening is above its normal location on the glans of the penis. less common

Treatment Epispadias & Hypospadias

Surgical correction between 6-12 months

Acute glomerulonephritis

Inflammation injury in the glomerulus

Clinical manifestations glomerulonephritis

Hematuria(smokey or tea colored urine), proteinuria(0-3+), edema especially in face arms and legs, hypertension`

When do clinical symptoms of glomerulonephritis present

1-2 weeks after streptococcal pharyngitis, 3-6 weeks after streptococcal skin infection

Treatment glomerulonephritis

Symptomatic and supportive management, antibiotics, antihypertensives, diuretics, fluid and electrolyte management, low salt diet(most important)

Nephrotic syndrome

idiopathic kidney disorder characterized by proteinuria, hypoalbuminemia and edema, most frequent in children 2-6 year old. exacerbation and remissions, relapses rare in adolescence

Symptoms nephrotic syndrome

Severe proteinuria(3+-4+), dark, frothy urine, weight gain, anorexia, edema that worsens as day goes on, abdominal pain, pallor, fatigue, respiratory infection, normotensive

Management nephrotic syndrome

Prednisone, diuretics, possible albumin administration, no added salt diet, no live virus vaccines, assess skin integrity, prevent infection, parent education on communicable diseases(infection precautions)

Acute kidney injury

Sudden, severe loss of kidney function, improves after underlying condition corrected

Manifestations AKI

Electrolyte abnormalities, fluid shifts, increased BUN and serum creatinine levels, acid based imbalances, poor feeding, decreased appetite, vomiting, lethargy, seizure, pallor

Indications for dialysis AKI

Severe fluid overload, pulmonary edema or heart failure secondary to fluid overload, severe hypertension, metabolic acidosis or hyperkalemia not responsive to medications, blood urea nitrogen greater than 120mg/dL

Chronic renal failure

An irreversible loss of kidney function over months to years, end stage renal disease, families that are affected require multidiciplinary care, kidney transplantation

Heart Failure

The hearts inability to circulate sufficient blood to meet metabolic demands of the body. Initially increase in heart rate, over time heart becomes enlarged. Muscles become weak and inefficient

Common signs of HF in children

Poor weight gain and failure to thrive

S+S of HF children

• Tachycardia, cardiomegaly,

• Gallop rhythm,

• decreased peripheral perfusion,

• excessive diaphoresis(especially in the head),

• weight gain, ascites, hepatomegaly, edema, Neck vein distention,

  • dyspnea, rales, tachypnea, chest retractions wheezing

Management of heart failure

Allow for uninterrupted rest periods, avoid strenuous exersize, avoid high altitudes, provide O2 during stressful periods

Medical management heart failure

Digitalis, calcium channel blockers, diuretics, warfarin, supplemental oxygen(o2 is a vasodilator and can increase pulmonary blood flow)

Pulmonary hypertension

Elevated BP in lungs

Diagnosis Pulmonary HTN

Pulmonary arterial pressure >20mmHg at rest(normal at rest 15MMHG)

Pathophysiology pulmonary HTN

Initially occurs with left to right shunting, vascular changes eventually lead to vessel wall thickening and severe vasoconstriction, right to left shunting then occurs

Cyanosis in heart conditions

Desaturated blood from venous system enters the arterial system without passing through the lungs

When does cyanosis become visible in children

When O2 Sats drop below 85%, pale and mildly cyanoic makes child appear “dusky”, which intensifies with crying

Polycythemia

Consequence of cyanotic heart conditions. Increase in RBC and decrease in platlets, at risk for bruising, prolonged bleeding, and CNS injury