Pediatric Exam 2: School Age Child/Adolescent Developmental Notes, Acute Pediatric Illnesses Notes: Respiratory, Cardiac, GI, GU

Prevention of Bronchiolitis

*Palivizumab (Synagis):* -Like a vaccine, except is antibody -Monoclonal antibody given monthly intramuscularly to at-risk children -Only given august to march to certain at-risk children (premature infants or those with respiratory or heart conditions) -Very expensive medication (immunoglobin, antibodies! Lasts about a month) can prevent bronchiolitis. B/c expensive only given to certain population of infants who are at higher risk

What ages are considered to be school aged?

6-12 yrs -Wong defines this period as 'beginning with losing deciduous (baby) teeth & ending with puberty' -Height increases 2 inches per year, has pre-pubescent growth spurt -weight increases 2-3 kg per year -Gain skeletal length, lose fat, gain muscle: genders do this at different rates though-at 6 boys are taller and heavier than girls, but at 12 girls are taller & heavier than boys *start to get deciduous teeth at 6 months and start to lose them at 6 yrs.

Erikson (Psychosocial) Development: School Age Kids

Industry vs Inferiority stage (age 5-12 yrs) -eager to perform tasks (want to work, want to learn things. Start to feel inferior to others if they can't do things) -Performing tasks well gives them sense of accomplishment -Reinforcement of accomplishment from peer approval, grades, privilege, recognition (like being told they did a good job, like trophies) -Increased sense of independence -Feelings of inferiority occur from self or social interactions -*Children with disabilities at a disadvantage*: already at a disadvantage for reaching milestones, so they struggle more with this stage -All children feel some degree of inferiority with skills they cannot master

Body image & concerns r/t growth & development (School Aged Kids)

*Children like their physical selves less as they grow older:* -The head is the most important part of a school age child's perception of themselves (school age kids are worried about their facial structures/face not worried about their bodies yet) -Body image is influenced by significant others (Family significant adults, peers) -Increased awareness of 'differences' may influence feelings of inferiority *School is a huge part of school-age children's lives:* -Increases child's independence from parents/family -Teachers become significant adults, children seek approval from them -Parents supplement school programs (support or inhibit children from meeting school goals) -Spend a lot of time at school, and it can cause a lot of stress and stress can come out in terms of anxiety, school aversion, constipation, emotional reactions (getting in trouble at school) *Discipline and limit setting should instruct & guide positive behaviors:* -strategies include withholding privileges, imposing penalties, contracting *The school environment can cause stress & fear:* -Parents/adults to need to help identify & explore causes *Big causes of fear in this age are death, being hurt (need reassurance)* -These kids worry about their parents dying while they're not with them and getting hurt is also a big fear (they think when they get hurt its definite/final)

Nutrition, Sleep, & Exercise (School Aged kids)

*Nutrition:* -Food likes & dislikes identified in preschool age continue -Food choices in the home setting are depending on parent choices, while food choices in the school setting are under child's control -Might be more open to trying new food, but they'll stick with what they like; strong food preferences -Kids start to make their own food choices b/c can prepare snacks for themselves, can pick out what to order at lunch, etc. *Sleep:* -Need an average of 9.5 hrs/night -Younger school-age children have bedtime resistance, this decreases with age *Exercise:* -Children like to increase their skills and enjoy team competitions -Usually kids enjoy exercising

Diagnosis of APSGN (Acute poststreptococcal glomerulonephritis)

*Diagnosis:* -Moderate edema on physical exam -Urinalysis shows hematuria & proteinuria (parallel increases between these two lab values) -Urine looks discolored d/t hematuria -Elevated BUN d/t decreased filtration -Antistreptolysin O titer for GABHS -Serum Component (C3) levels are decreased in acute APSGN, this level is used to assess recovery (as it rises, child is recovering) -Chest x-ray: enlarged cardiac silhouette, pulmonary congestion Notes: -Diagnosis of glomerulonephritis is usually first on the presence of edema, and then on UA with proteinuria AND hematuria (these two values usually increase at the same time, in the same amount). -The patient can have a increased BUN (from decreased kidney filtration), and a positive ASO titer (from GABHS infection- remember this lab from Rheumatic fever?). -Serum complement levels (C3) are decreased, and this lab value is used to assess recovery. As the complement level increases, the child is recovering. -Because of the increased fluid in the circulatory system, this can cause pulmonary congestion and backup of fluid into the heart, leading to an 'enlarged cardiac silhouette' on chest x-ray.

Esophageal Atresia & Tracheoesophageal Fistula

*Esophageal Atresia (EA):* -Congenital -Esophagus ends in pouch, so not connected to stomach *Tracheoesophageal Fistula (TEF):* -Congenital -Trachea connects to esophagus (through a fistula which is an abnormal connection) -EA and TEF are both congenital malformations where the esophagus does not connect to the stomach, and possibly has a fistula leading to the tracha (TEF). -Obviously, a person with one of these issues will either not be able to eat or will have their food going to their lungs (not safe) -There is no safe eating in both of these situations b/c not going to the stomach in these situations -It can be associated with cardiac anomalies, so a child born with EA or TEF should be assessed for cardiac issues -Eating is not effective for either defect: food/fluid either fills pouch (EA) or goes to the lungs (TEF) -Surgical correction is expected *Signs and symptoms:* -3 C's choking, coughing cyanosis (TEF), -Respiratory distress when eating -Frothy mucous from the mouth -Abdominal distention *Diagnosis:* Sometimes recognized in utero, but if not it is suspected based on symptoms and then a chest x-ray is done (sometimes with a catheter inserted into the pharynx to assess for obstruction) *Treatment:* -Preop: immediate NPO status, IV fluids, NGT placed to low wall suction, suction oral secretions HOB up to prevent aspiration. Often child will have either a G-tube placed for nutrition or will receive parenteral nutrition by IV (usually a central line) -The child will have a surgical repair of the site, and post-op care is very similar to pre-op care (NPO, IV hydration, NGT to low wall suction or gravity, and nutrition initially either via parenteral nutrition or G tube, pain management) -NPO, IVF/TPN or G tube until surgical site is healed (then transitioned to PO) Before oral feeds are given, a barium swallow test is done to ensure the integrity of the surgical site -Oral feeds are first started as sterile water, then small frequent feeds of breast milk or formula. Until the infant is supporting themselves with POs, G tube feeds may also be given *Long Term Complications of EA & TEF:* Respiratory Complications -In addition to pneumonia and respiratory distress, laryngeal edema can also occur both pre-op and post-op -For children with TEF, there is a risk for tracheomalacia (a narrowed trachea) due to the fistula and fistula repair. Parents should be taught signs or respiratory distress and esophageal narrowing (choking, drooling, vomiting undigested food), and to report these to their provider -The child's weight gain will be carefully assessed in the first year post-op, and assessment of milestones is also important in case the child needs support from early intervention *Very fixable but either need to know in utero or early on to fix it

Stages of Puberty

*Females:* 1. Thelarche (8-13 yrs): Breast buds -average age is 10 yrs for caucasians (range 8-12 yrs) -average age is 9 yrs for Afr. Americans (range 7-11) 2. Adrenarche (8-13 yrs): Pubic hair growth -Occurs 2-6 months after thelarche 3. Menarche: occurs about 2 yrs after thelarche: -Average age 12 yrs 4 months (range 10.5-15) Puberty "delay": -No thelarche by age 13 yrs -No menarche within 4 yrs of breast development *Males:* -Stage 1 (9.5-14 yrs): testicular enlargement and sparse pubic hair -Stage 3: penile enlargement, voice changes, early facial hair; gynecomastia (temporary breast enlargement) occurs in 1/3 of males in midpuberty -Stage 5: Penile growth, first ejacuation, axillary, groin, and facial hair, final voice change *Puberty 'delay:* -No enlargement of testes or scrotal changes by 13.5-14 yrs -Genital growth is not complete 4 yrs after testes enlarge

Treatment of Enuresis (School Aged Kids)

*First line treatment:* -Bladder training: regular voiding, voiding before bed -Fluid restriction in evenings -Interruption of sleep to void: parents wake up child before they go to bed or set alarm in the middle of the night to wake up child -Condition reflex response device: bed wetting alarms, wake child up when bed is wet *Second line treatment:* Drugs -Desmopressin (DDAVP): 1st line med for nocturnal; similar to vasopressin, inhibits filtration of fluid at the kidney; Recommended oral versus nasal spray (hyponatremia); this is the important med to know -Imipramine (Tofranil): tricyclic antidepressant, has anticholinergic action on the bladder to inhibit voiding; Relapse is common when medication is stopped (given for up to 8 weeks, then tapered off over 4 weeks) -Oxybutynin (Ditropan): anticholinergic/antispasmotic: inhibits smooth muscle constriction of the bladder

Erikson's Psychosocial Development (Adolescents)

*Identity vs Role Confusion:* -Early adolescent: Group identity vs alienation (group identity must be established before personal identity) Trying to find their identity, take on a group identity around 12-13, trying to fit in with their group; once they feel accepted by the group, they start to branch off into their own personal style; *group identity prior to personal identity* -Personal identity: forming an identity has periods of confusion, depression, and discouragement; Positive identity eventually emerges -Sex role identity: culturally acceptable romantic relationships -Emotionality: can have unpredictable mood swings

Constipation (GI Illness)

*In infancy:* First meconium should be passed within 24 to 36 hrs of life; if not, assess for: -Hirschcprung disease -Hypothyroidism -Meconium plug or meconium ileus (cystic fibrosis) -Formula fed infants may develop constipation: can add veggies at 6 months, also do leg bicycles with them a few times a day) -Nursing management: Prune juice at 6 months *In childhood:* -Due to environmental changes, or control over body functions -May result from stress -Relationships to urinary tract infections -Nursing management: Routine toileting every AM, laxatives; Age + 5 grams = fiber intake Notes: -Constipation usually affects a child at least once in their life -Constipation in newborns is occasionally the hallmark of a disease process (such as Hirschsprungs disease, hypothyroidism, or cystic fibrosis), but more commonly it is due to being formula fed -The most common intervention for a formula fed infant who has constipation is the addition of pureed veggies, around 6 months of age. -A common laxative used in young infants to help them initiate a bowel movement is prune juice- pharmacological PO laxatives like senna and miralax are avoided, though rectal laxative suppositories may be used in infants. -Other times children commonly experience constipation are when they wean from breastmilk to cow's milk (around 1 year of age), and then again either when they are toilet training (around age 2-3) or when they start to attend preschool or kindergarten (age 4-5). The constipation from cow's milk can occur because breastmilk keeps stools soft and moving easily, so in this case increasing other fluids (water or diluted juice) and small amounts of fiber should help. -Children who experience constipation during toilet training often have this occur because they are so focused on playing that they do not want to stop to poop, or they are not comfortable on toilets yet so they only want to use their own toilet at home and will hold their stool until they are home. -Children who experience constipation when they are starting to attend preschool or kindergarten usually experience this due to stress from the new structure change and environment, and also can be from the new bathroom facilities they have to get used to -*Treatment for constipation for children older than age 3 is fiber*; they should get enough grams of fiber each day to equal their age, plus 5 (so a 4 year old would get 9 grams of fiber per day). -Children over age 3 can also begin to take PO miralax mixed in juice or milk. These children should have structured bathroom time, and usually after breakfast or dinner is a great time to have the child sit on the toilet for up to 5 minutes to give their body the chance to have a BM. -Occasionally long standing constipation can lead to hard stools in the colon with impaction; children may require abdominal x-rays for constipation and an admission to the hospital for enema and bowel clean-out. -Usually constipation is managed in primary care setting, but if really severe might have to go to hospital for clean out

Injury Prevention & Anticipatory Family Guidance

*Injury Prevention:* -Most common cause of severe injury & death in school-age children is motor vehicle crashes (pedestrian and passenger) -Most injuries near home or school -Education is most effective at preventing injuries; really important in preschool years to reinforce importance of wearing helmets, seatbelts, how to cross street, etc. (also fire injuries and firearm injuries) -Bicycle injuries; benefits of bike helmets: falls from bikes cause many head injuries -Appropriate safety equipment for all sports *Anticipatory family guidance:* -Parents adjust to the child's increasing independence -Parents provide support as unobtrusively as possible -Child moves from narrow family relationships to a broader world of relationships -Parents have to understand that kids are supposed to become more independent. Parents should guide them so they can make good decisions

Adolescents: Injury Prevention & Anticipatory Guidance

*Injury Prevention:* -Motor vehicle crashes are the single greatest cause of serious and fatal injuries in teens -Other vehicles (motorcycles, ATVs, jet skis) -Firearms and other weapons -Sports injuries -Poisoning, tobacco, alcohol, and other drugs -Adolescents think they are invincible *Anticipatory Guidance:* -Parents need support and guidance about development changes and process of gaining independence -Need to be consistent loving supports

Adolescents: Informed Consent

*Patient or patient's legal surrogate give consent:* -For minors, if parents are married only one parent needs to give consent -If divorced, parent with legal custody gives consent -If parent is not present and the child is at risk for dying or having permanent injury, care may be given -If a parent denies needed care, child protective services should be notified -Person must be capable of giving consent -Must be over 18 years old -Must receive all information needed to make an informed decision -Older children/adolescents should give assent (not legally required); explain procedure to them to see if they are okay with it -Means child has been informed about the treatment and is willing -If parent consents to a procedure but a the older child/adolescent does not assent ask him why he doesn't want it/figure out why (show him what result of procedure will look like, where it occurs, if there is scarring); Explain long term consequences of not doing it; can go to ethics board; remember you are his advocate too!

Social development & relationships (School Age Kids)

*Peer group* is the most important socializing agent: -Daily interaction at school teaches children to appreciate others' points of view and to understand social/cultural norms -Peer groups give children information about belonging to groups/cultures (standards for acceptance and rejection): children may take on 'roles' for acceptance (class clown, mean girl) -Also teach dominance, leadership, authority: needed for gaining independence from parents; increasing independence from parents is the *primary goal* of the school aged child -School aged children form groups or clubs -Early in childhood groups are fluid and loosely organized, but with age comes rigid rules, exclusivity & conformity -Having 1 'best friend' is common Notes: -Peer groups outside of school are really important, shows them how to act in dif situations, how to dress, etc. -Going to a friend's house after school, having sleepovers on weekends, helps them gain independence, become comfortable being away from family.

Adolescents Relationships with Parents & Peers

*Relationships with Parents:* -During adolescence, role changes from 'protection-dependency' to "mutual affection and equality" (this role change process involves turmoil and ambiguity) -Emancipation from parents may begin with the rejection of parents by the teenager -Teens focus time on peer group/friends -Confide less in parents, but parents still influence (parents give advice and stuff when asked) -Late adolescents are mentally competent to be independent, but lack financial resources -Parent oversight may deter poor decisions (alcohol, drug use): Parent SHOULD use authoritarian approach with clear, consistent messages and expectations; also need to respect privacy and show honesty to preserve trust *Relationships with Peers:* -Peers assume an increasingly significant role in adolescence: groups allow for acceptance, self learning and self reliance; best friends are important for developing identity -Peers provide a sense of belonging and a feeling of strength and power -Peers form a transitional world between dependence and autonomy

Acute Pediatric Illnesses: Respiratory and Cardiovascular

*Respiratory Acute Illnesses:* -Pharyngitis -Tonsillitis/Tonsillectomy -Otitis media -Mononucleosis -Croups -RSV & Bronchiolitis -Pertussis *Cardiac Acute Illnesses:* -Diagnostic evaluation: Cardiac catheterization -Congenital Heart Disease: VSD, ASD, COA, AS, PS -Infectious Endocarditis -Rheumatic Fever

Adolescents Development of Self-concept & Body Image

*Response to Puberty:* -Responses differ depending on the stage of development: -Curiosity in early adolescence -Concerns with "Am I normal?" -Concerns for late-maturing teens -Concept of "perfect body" achievement *Body Image:* -Body changes lead to feelings of confusion in early adolescence -Acute awareness of appearance, comparison of appearance with others -Blemishes and defects are magnified out of proportion -Matures to self-concept based on uniqueness and individuality Notes: -telling teenagers what's going to happen next is important -Reassuring them about their bodies *Body image/body perception common answer to adolescent exam Qs

Dehydration (GI illness)

*Severity:* -Not many signs with mild dehydration, just less urine -First sign with moderate = tachycardia *Infants: -mild: 3-5% body weight loss -moderate: 5-9% body weight loss -severe: > 10% body weight loss *Children: -Mild: 3-4% body weight loss -Moderate: 6-8% body weight loss -Severe: 10% body weight loss *Treatment for Mild to Moderate Dehydration:* Oral Rehydration -Mild: 50 ml/kg over 4-6 hrs -Moderate: 100 ml/kg over 4-6 hrs *Treatment for Severe Dehydration:* IV Replacement -Start with NS 20 ml/kg in 20 minutes, repeat x 2 -Return to maintenance therapy, assessing q 8 hrs Notes: -Diagnose first based on symptoms -Can categorize its severity based on weight loss -Either have them drink orally or give IV fluids (usually chosen based on whether mild/moderate/severe and why they aren't drinking) -If vomiting: oral is not the best route! -Oral rehydration: sometimes use syringe with little ones (full of pedialyte) filling 10 ml syringe and giving them 2 ml sips

Adolescents: Sexuality & Health Promotion

*Sexuality:* 1. Dating: -Common in middle adolescence, first relationships are non-committal and loose 2. Sexual identity: -Orientation is a part of this -Milestones of sexual identity (pg. 486) 3. Sexual Experimentation (wide range) -Average age of sexual debut is 17 -Formal operations assists in decisions Reasons for sexual experimentation: -Curiosity: want to know what all the hype is about -Pleasure -Conquest -Peer pressure to conform: want to be doing what everyone else is doing *Health Promotion:* -Adolescent begins to assume personal responsibility for health; adolescents need to take charge of their health decisions -Nutrition/eating behaviors are more independent -Sleep & Rest still needed during periods of growth -Very influenced by media, peers -Need factual information & to be able to ask questions -Need to know how to protect themselves from infections/STDs

Comparison between Nephrotic Syndrome & APSGN

*Similar:* -Both more common in school aged boys -Both affect the kidneys -Both require monitoring of proteinuria -Both have edema -Both have anorexia -Both have sodium restriction -Both MAY have fluid restriction *Different:* -More edema in Nephrotic syndrome -More proteinuria in Nephrotic Syndrome -Risk of infection in Nephrotic syndrome -Risk of relapse in Nephrotic syndrome -Treatment with steroids in Nephrotic -Hematuria in APSGN -Seizure risk in APSGN -Increased BP in APSGN

GI: Review of Dehydration

-Total Body Water (TBW): Intracellular (ICF) and Extracellular (ECF) -Extracellular Fluid: Intravascular, Interstitial, Transcellular *Maintenance water requirements:* -Replaces insensible (skin, respiratory), evaporative losses, urine & stool -Infants/toddlers lose more, need more than adults: Fever/increased RR increase losses; Kidneys are immature *Altered Fluid requirements in various Conditions:* -Requires assessment/awareness *Reasons Children Get Dehydrated:* -Increased RR during illness -Fever -Vomiting -Diarrhea -Drainage tubes (fluid loss) -Phlebotomy -Phototherapy (newborns)

Treatment of APSGN (Acute poststreptococcal glomerulonephritis)

*Treatment:* -Outpatient treatment & monitoring is appropriate for those with normal BP & urine output *Inpatient monitoring is needed for those w/ hypertension, edema, oliguria:* -Sodium restriction -Fluid restriction -I&Os, daily weights -Monitoring and Treatment of hypertension: Monitor BP q 4-6 hrs, hypertensive meds, diuretics -Seizure precautions for increased BUN/Azotemia -Acute renal failure is a rare possibility, treated by dialysis -Patient may develop nephrotic syndrome from APSGN, if proteinuria is excessive -Treatment with antibodies if longstanding GABHS infection is found Notes: -Treatment can be outpatient if the patient has normal blood pressure and urine output, or in-patient if a patient has hypertension, edema, or oliguria. -In-patient management includes sodium restriction, fluid restriction, strict I/O's, daily weights, and close BP assessments (could be on beta blockers and diuretics to manage hypertension). -If the BUN is increased, the patient should be on seizure precautions due to the risk of seizures, and can go into acute renal failure (if this occurs, the patient needs dialysis). -Patients CAN develop nephrotic syndrome from this, if the proteinuria is excessive (4+-5+). This is not treated with antibiotics though, UNLESS the patient has a GABHS infection.

Diarrhea: Viruses/Bacteria (GI Illness)

*Viruses:* -Rotavirus is #1 cause of gastroenteritis in children -Giardia is the most common cause of diarrhea though (on ATI) -Age 3-24 months are most at risk (spread fecal-oral route- handwashing is important!!) -Up to 70,000 hospitalizations annually -Prevention: rotavirus vaccine (2 types given at 2 mo, 4 mo, 60 mo); Can be spread in stool after vaccination- educate parents on handwashing; contact precautions in hospital *Bacteria:* -Salmonella, Shigella, Campylobacter Notes: -Diarrhea in children is usually caused by a pathogen spread fecal-orally. -Infants may have more diarrhea because their immune system is still building itself, while toddlers can have more diarrhea because of their tendency to put items in their mouth and need assistance for hand hygiene. -Rotavirus is the #1 cause of diarrhea in children, and almost all children have had this virus once by the time they are 5 years old. It is also the most common pathogen in hospital admissions for diarrhea. -There are a few bacteria that cause diarrhea (salmonella, shigella, and campylobacter) and a person can get these through undercooked foods, contaminated foods, or via fecal-oral route. -The management of diarrhea is through oral rehydration. -*Oral rehydration solution should be given in 10ml increments, every 5 minutes, at the weight based volumes (either 50ml/kg or 100ml/kg)* . -After rehydration, the child should be encouraged to eat as normal (though their stool frequency may initially increase). -In the hospital setting, nursing care for a child with dehydration focuses on rehydrating the child (either via IV or PO), encouraging good handwashing by the patient and parents, and monitoring strict intake and output.

Influenza (respiratory illness)

-3 types of influenza, many strains: Type A and B affect humans -Droplet precautions -'Flu shot' protects against the anticipated major strain of influenza: trivalent (3 dif strains in one vaccine) or quadrivalent (4 dif strains in one vaccine) -Everyone age 6 months and older should get a flu vaccine; age 6 months to 8 yrs: get 2 doses of flu vaccine 1st year -'Flu shot' = inactivated or recombinant (injection) -Live vaccine: nasal liquid (Age 2 yrs to 49 yrs w/o history of asthma or egg allergy)' REMOVED from market 2016 because wasn't working as well -All flu vaccine (live or dead) have egg protein in them, however now ALL are recommended to get the flu vaccine (even if allergic to eggs- if anaphylactic reaction to eggs, should still get flu shot just in a setting where they could help you!)

Classification of Congestive Heart Disease- Congenital Defects)

-4 types 1. *Increased Pulmonary Blood Flow* -Atrial Septal Defect (ASD), Ventricular Septal Defect (VSD) 2. *Decreased Pulmonary Blood Flow* 3. *Obstruction of blood flow out of the heart:* -Coarctation of the aorta (COA), Aortic Stenosis (AS), Pulmonic Stenosis (PS) 4. *Mixed Blood flow*

Acute Viral Nasopharyngitis (respiratory illness)

-Acute viral nasopharyngitis = current inflammatory process viral infection of the nose and pharynx -Common Cold! -Infection/inflammation of the nasopharynx, pharynx &/or larynx -Numerous infectious causes (usually viral- so not treated with antibiotics) -Diagnosis: on clinical signs/symptoms (no other swabs/tests unless worried about it being caused by something) -Home: only treatment for kids < 6 yrs is nasal saline & bulb syringe; encourage fluids, handwashing, nasal bulb syringe -Not treated with medications (unless maybe tylenol for fussiness in little ones); parents tend to overuse decongestants and it can lead to overdose or rebound congestion -Hand hygiene is crucial -Also encourage fluids b/c it's easier to drink than it is to eat when congested so it is beneficial, nasal bulb syringe for children under 18 months

Wilms Tumor (Nephroblastoma)

-Aka Nephroblastoma -Malignant renal and intra-abdominal tumor of childhood -Peak age of diagnosis is 3 yrs *Signs & symptoms:* -Painless abdominal mass or swelling -Firm, nontender unilateral, toward the back -Parents usually find it during ADL's -Other S&S's include hematuria, weight loss -Can have hypertension d/t renin secretion from tumor -Metastasis is usually to lungs *Diagnostic Evaluations:* -Abdominal ultrasound/CT (to see area/size- if very large can affect vena cava) -Renal studies (to assess kidney function) -Lung CT (to assess for metastasis) Notes: -Wilms Tumor is a kidney tumor (also called nephroblastoma). This cancer usually occurs in young children, with the peak age of diagnosis being at 3 years old. -Initial signs and symptoms of nephroblastoma are a painless abdominal mass or swelling. This mass is firm, non-tender, usually unilateral and toward the side and back of the abdomen (think about where the kidneys are located). -Parents usually first notice the enlarged area when either bathing or dressing their child. -Other symptoms that may be noticed initially include hematuria and weight loss. -A child with a nephroblastoma may have hypertension due to increased renin production from the tumor, and if there is metastasis it is usually to the lungs. -Diagnosis is on abdominal ultrasound and/or CT scan to assess for the tumor, renal studies to assess the kidney function and involvement, and then a lung CT scan to look for metastasis. *Therapeutic Management:* Surgical Removal of tumor with whole nephrectomy ASAP -Other kidney is inspected, along with lymph nodes & close structures -If both kidneys are involved, may need partial nephrectomy or require dialysis and renal transplant -Chemotherapy in all stages, and/or radiation (depending on the size of the tumor) -90% of children have 5 yr cure *Nursing Considerations:* -Support the family: treatment moves quickly after diagnosis -Do not palpate the abdomen pre-surgery -'Typical' preoperative/postoperative care (NPO, IVF, pain management, inspecting incision sites, monitoring I&Os, clear liquid diet initially post-op) -Monitor BPs afer diagnosis/surgery/during chemotherapy -Monitor for side effects of chemotherapy -Monitor for infections during chemotherapy Notes: -Treatment of a nephroblastoma is immediate removal of the tumor and affected kidney, followed by chemotherapy and possibly radiation therapy. -While the child is in surgery, the other kidney will be inspected for any signs of cancer, along with having regional lymph nodes inspected for involvement. -If the child has bilateral nephroblastomas (one on each kidney), they will either have partial nephrectomies done with the tumor removals, or will have the kidneys removed and will need dialysis and a renal transplant. -Nursing consideration include supporting the family (treatment moves quickly once the diagnosis is confirmed), not palpating the abdomen before surgery (in case of disturbing the tumor capsule and spreading the cells), providing the anticipated pre-op and post-op surgical care, monitoring blood pressures, and during chemotherapy monitoring for side effects of chemo and infections.

Rheumatic Fever

-An inflammatory disease that occurs as a reaction to Group A beta-hemolytic streptococcus (GABHS) infection of the throat *Risk Factors:* -Rheumatic fever usually occurs within 2-6 weeks following an untreated or partially treated upper respiratory infection (strep throat) with GABHS *Expected Findings (Signs & Symptoms:* -History of recent upper respiratory infection -Fever -Tachycardia, cardiomegaly, prolonged PR interval, new or changed heart murmur, muffled heart sounds, pericardial friction rub, and report of chest pain which can indicate carditis -Non tender subcutaneous nodules over bony prominences -Large joints (knees, elbows, ankles, wrists, shoulders) with painful swelling, indicating polyarthritis (findings can be present for a few days and then disappear without treatment, frequently returning in another joint) -Pink, nonpruritic macular rash on the trunk and inner surfaces of extremities that appears and disappears rapidly, indicating erythema marginatum -CNS involvement (chorea) including involuntary, purposeless muscle movements; muscle weakness; involuntary facial movements; difficulty performing fine motor activities; labile emotions; and random uncoordinated movements of the extremities -Irritability, poor concentration, and behavioral problems *Lab tests:* -Throat culture for GABHS -Serum antistreptolysin-O titer: elevated or rising titer, most reliable diagnostic test -C-reactive protein (CRP): elevated in response to an inflammatory reaction -Erythrocyte sedimentation rate: elevated in response to an inflammatory process *Diagnostic Procedures:* Cardiac function -ECG to reveal the presence of conduction disturbances and to evaluate the function of the heart and valves -Echocardiography to document pericardial effusions -Nursing actions: position the child correctly for the procedure, explain that they need to stay still for the procedure *Jones criteria:* -The diagnosis of rheumatic fever is made on the basis of modified jones criteria. The child should demonstrate the presence of two major criteria or the presence of one major and two minor criteria following an acute infection with GABHS -Major criteria: Carditis, subcutaneous nodules, polyarthritis, rash (erythema marginatum), chorea -Minor criteria: fever, arthralgia *Nursing Care:* -Encourage bed rest during the acute illness -Administer antibiotic as prescribed -Encourage nutritionally balanced meals -Assess for chorea (a neurological disorder characterized by jerky involuntary movements affecting especially the shoulders, hips, and face.) *Medications: Antibiotic prophylaxis:* -Follow the prescribed prophylactic treatment regimen, which can include one of the following: 1. two daily oral doses of 200,000 units of penicillin, 2. Monthly IM injection of 1.2 million units of penicillin G, 3. Daily oral dose of 1 g sulfadiazine -The length of treatment varies according to residual heart disease, ranging from 5 yrs to indefinitely. -Nursing Considerations: Assess for an allergic response, Assess for nausea vomiting diarrhea -Encourage compliance with medication regimen *Client education:* -Promote rest during the acute phase -Provide info and reassurance related to the development of chorea and its self-limiting nature -Encourage well balanced meals -Seek medical care if infection recurrence is suspected -Complications: Carditis, and heart disease

Appendicitis

-Appendicitis is inflammation of the appendix, located in the lower right-hand quadrant of the abdomen. Inflammation of the appendix can lead to obstruction and subsequent perforation (which can lead to peritonitis, sepsis, and shock); Can be life threatening if the appendix perforates! *Signs and Symptoms:* not uniform, can vary from patient to patient, but usually include: -abdominal pain (which is over the entire abdomen at first, then moves to the right lower quadrant) -Fever -Vomiting. *Diagnosis:* -Usually from abdominal ultrasound to look for inflammation -Increased WBC -Increased CRP level -Occasionally an abdominal CT scan if the ultrasound cannot visualize the appendix -Other diagnostics that may be performed include: urinalysis for possible UTI, and urine hCG for possible ectopic pregnancy in females over the age of 12 *Treatment of Non-perforated appendicitis:* -Surgical removal of the appendix (appendectomy) -IV antibiotics are given before the surgery *Treatment of a Ruptured Appendix:* -Consists of IV fluids and antibiotics -Abdominal ultrasound or CT scan to assess for inflammation or abscess -Possible surgery for drainage of an abscess -Possible NGT placement for stomach decompression *Nursing Care for Post Op:* -Pain control (hopefully transitioning the child off IV pain medication in 12 hrs) -Assessing the incision site(s) for healing and infection -Increasing mobility (hopefully able to walk the hall in the hospital 6-12 hours after surgery) -Increasing POs (starting with clear liquids after surgery, then progressing to a soft diet, and finally full diet) -Children are typically discharged 24-48 hrs after an appendectomy

Croup Syndromes (respiratory illness)

-Are a category of different infections -Are infections of the epiglottis, larynx, trachea, & bronchi -Epiglottitis, Layngitis, Spasmodic laryngitis, Acute Tracheitis, Laryngotracheobronchitis -Generally 'croup' is laryngotracheobronchitis -Younger children get LTB -Older children get epiglottitis: life threatening!

Pertussis (Whooping Cough) (Respiratory illness)

-Bacteria Bordatalla pertussis attaches to cilia in the upper respiratory tract and damages the cilia, leading to inflammation with edema -Prevention: DTaP vaccine for age 2 months-6 yrs/Tdap booster age 11 and up (also Tdap at each pregnancy around 27-30 weeks gestation) -Spread by droplets -Symptoms begin 5-10 days after exposure, and person is contagious for 2 weeks after cough begins: *Symptoms occur in 3 stages:* -Stage 1: Cararrhal stage (7-10 days long) with cold like symptoms, maybe a low grade fever -Stage 2: Paroxysmal stage (1-6 weeks long) with paroxysms of rapid coughs due to thick mucous. "Whoop" begins due to decreased oxygenation with the coughing (coughing so hard unable to get oxygen, which creates the whooping sound). Cyanosis and vomiting may occur with coughs (coughing so hard they vomit, or turn blue because coughing fit lasts so long). Young infants (0-6 months) may never cough, but instead have periods of apnea with cyanosis Stage 3: Convalescent stage (7-10 days long) with gradual recovery from coughing -Diagnosis: via nasopharyngeal swab -Treatment: antibiotics (erythromycin), humidified air to reduce inflammation, nasal suctioning, monitoring for intake and risk for dehydration due to decreased PO's -Complications: impaired ventilation in infants, pertussis associated pneumonia, broken blood vessels in eyes from coughing

Sex Education & School Health

-Child's attitude about sex is established at an early age -Parent reluctance to discuss may lead to idea of sex being 'dirty' & gaining misinformation from peers *School age is the ideal time for formal sex education:* -Normal part of growth and development -Average age of puberty is 10 yrs in girls and 12 yrs in boys -Honest but age appropriate answers -Life span approach -Information of sexual maturity and the process of reproduction -Effective communication with parents *Child's health is ultimately the responsibility of the parent:* -Parent is still the primary person to manage their kids health -Schools/teachers assist in educating about health and supporting child's health -School nurses are vital for: 1. Educating children on health issues 2. Identifying current developmental or health problems 3. Providing care that is needed 4. Managing/educating teachers regarding infections and emergencies 5. Coordinating care with parents, emergency departments, primary care, specialists

Normal Characteristics of Urine

-Color range -In newborns, production is 1 to 2 ml/kg/hr -In children, production is about 1 ml/kg/hr -pH: 5.0-9.0 (pathogens like alkaline) -*Specific Gravity: 1.001 to 1.035*; shows concentration of urine is it diluted or concentrated? (Increases in specific gravity means more concentrated urine) -Protein: less than 20 mg/dl; usually some protein but less than this amount -Urobilinogen: up to 1 mg/dl -None of the following: glucose, ketones, hemoglobin, WBCs, RBCs, casts, nitrites *Diagnostics:* -Dipstick -Urinalysis -Urine culture (clean catch or sterile catheter) Notes: -In children, urine can have a variety of yellow colors, but is usually either clear or light yellow in color. Newborns produce about 1-2 ml of urine per kg per hour, while children (who can concentrate urine) produce about 1 ml/kg/hr. -

Infective Endocarditis

-Consists of Bacterial endocarditis & subacute bacterial endocarditis (old names) What is the pathophysiology of this disorder? -Infection of the endocardium: infection causes thrombi which can block blood vessels (usually in capillaries, eyes); Risks with prosthetic valves, recent cardiac surgery, rheumatic heart disease -Can be preventable: Antibiotic prophylaxis for previous infective endocarditis, prosthetic cardiac valves, unrepaired cyanotic defects, repaired defects with prosthetic material/devices in 6 months post-repair How is this disorder diagnosed? -Diagnosed: signs and symptoms: anorexia, malaise, weight loss, low grade fever, osler nodes (red, painful on pads of fingers), Janeway Lesions (painless areas on palms & soles), EKG changes, caridomegaly (abnormal enlargement of heart), growth on heart valves seen on echocardiogram, blood cultures How is this disorder treated? -Treatment: IV antibiotics x 2-8 weeks Notes: -Infection of the endocardium, the big risk is it can cause thrombi which can block blood vessels -At risk for infective endocarditis if have prosthetic valves, recent cardiac surgery, rheumatic heart disease -can also have splinter hemorrhages underneath fingernails

Extracellular Fluid Volume Defecit

-Total fluid output exceeds total intake *3 Types:* 1. Isotonic (most common): -Sodium and water are lost in equal amounts -sodium WNL (135-150) -IVF: D5W, 0.9% NS, LR 2. Hypotonic: -Sodium loss exceeds water loss (water moves from ECF to ICF) -Sodium < 130 -IVF: 3-5% NS, D5 0.9% NS, D5 0.45% NS 3. Hypertonic: -Water loss exceeds sodium loss (water moves from ICF to ECF) -Sodium > 150 -IVF: 0.45% NS

Management of Nephrotic Syndrome/Minimal Change Nephrotic Syndrome

-Education of Child and Parents *Diet:* -Sodium restrictions d/t edema, may have fluid restrictions with severe edema -Often have loss of appetite during illness (up to 2-3 weeks) *Steroids (1st line of therapy):* -Dose is 2 mg/kg/day divided into twice a day doses for 6 weeks, then 1.5 mg/kg/day every other day for 6 weeks -Predisone is the drug of choice (least expensive and safest) -Side effects of steroids *Diuretics for edema:* -Albumin transfusions for persistent edema *Frequent relapses or minimal effect with steroids:* -Relapses: do occur- parents should be taught how to monitor urine for protein with dipstick, look for edema. May be triggered by an infection -Immunosuppressant therapy (cyclophosphamide [Cytoxan]) Notes: -Nephrotic syndrome is managed via diet, steroids, and diuretics -Diet-wise, patients may have sodium restrictions due to the large amount of edema they have, and they have fluid restrictions with severe edema. Because their body is so sick, they may not have a good appetite. -Pharmacologically, nephrotic syndrome is treated with steroids to decrease inflammation. Prednisone is started at 2mg/kg/day divided BID x 6 weeks, then the dose is dropped to 1.5mg/kg/day every other day, for 6 weeks (12 week course of steroids). -Nursing care is focused on the side effects of steroids (decreased immune system and risk for infection). -The patients are also given albumin transfusions to pull the fluid that left the blood vessels and went to the interstitial spaces back into the blood vessels, and then diuretics are given so the patient urinates off any extra fluid that shifts back into the circulating volume.

Struggles for LGBTQ identifying children

-For healthy development, children (of all gender and sexual identities) need to feel socially, emotionally, and physically safe -Children who identify as LGBTQ have increased rates of bullying, violence, social anxiety, depression, and substance abuse (particularly after coming out); even if they are in a loving home *Nursing tips when caring for LGBTQ identifying children:* -Ask what pronouns and name they prefer to use -Be supportive and truthful when having conversations about gender and sexual orientation if initiated by the patent -Watch/screen for signs of depression in LGBTQ identifying children (excessive sleeping, loss of self-esteem, drop in academic performance, excessive secrecy, abandonment of friends/social groups) -Educate parents of LGBTQ identifying children on known health disparities in this population (parental support reduces the rate of suicide in LGBTQ identifying children)

Piaget's Cognitive Development (Adolescents)

-Formal operations period -Abstract thinking: ability to think beyond the present to the far future; understand long term consequences of actions -Mental manipulation of multiple variables -Concerned about others' thoughts and needs: can anticipate other's thoughts and points of view Notes: -Formal operations period: can do algebra, can think long term, can anticipate others thoughts and points of view

Adolescent

-Generally defined as beginning with the onset of puberty and ending with the cessation of body growth at 18-20 yrs -Transition between childhood and adulthood -Rapid physical, cognitive, social, and emotional maturation -Puberty: sexual maturity is achieved (menarche in girls) -Adolescence: time of growing into psychological, social, and physical maturation -Early adolescence: 11-14 yrs -Middle: 14-17 yrs -Late: 18-20 -Teenage: used synonymously with adolescent but refers to age 13-19 Notes: -a lot of emotional changes -Not uncommon for girls to get their periods while they are still in the school age group (don't worry so much about knowing early, middle, and late adolescence)

Adolescents Social Development

-Goal is to define one's identity independent from parental authority -Teens want to be independent but are fearful of responsibilities -Intense sociability occurs during adolescence to develop self identity: but even though teens are social, they often feel lonely -Acceptance by peers, a few close friends, and the secure love of a family are requisite for maturation Notes: -want to be independent and doing things on their own, but also worried about making it on their own -Often times feel like they aren't connecting with anyone (even peers) like no one understands them -Need to have acceptance by people other than family to be able to develop cognitively

Enuresis (school aged kids)

-Incontinence or night time bed wetting in a child who should have developed full continence (NOT due to medication or medical condition) -More common in boys (may be familial) -Usually ceases between 6 and 8 years of age *Diagnosis:* -Chronologic or developmental age over 5 yrs -Two times per week or more for 3 months -May have urgency or frequency -Physiologic causes (diabetes mellitus and UTI) are initially sought; usually rule out medical causes first *Primary enuresis:* onset of wetting in children who have never been dry for extended periods of time *Secondary enuresis:* onset of wetting after established urinary continence *Monosymptomatic enuresis:* most common; dry during the day *Polysymptomatic enuresis:* daytime urgency

Tonsillitis (respiratory illness)

-Infection inflammation of tonsils -Tonsils: lymph tissue, become inflamed with acute infections -Viral or bacterial -Signs and symptoms: edema, erythema -Diagnosis: clinical exam or culture (usually viral so usually presumed to be, but can do a strep test to see if it is causing it; if person has recurrent tonsillitis they might culture to see what is causing it -Treatment: antibiotics for GABHS -Nursing interventions: same as strep (warm water gargles, tylenol/motrin, cool drinks, soft foods, cold foods, increase fluids) *Removal of Tonsils- Surgical Care:* -No oral suctioning -No straws *no oral suctioning/straws b/c have sutures in back of throat, and don't want to disturb them and straw could also nick the sutures -Pain management (usually only oral after awake post-surgery); typically only oral tylenol/motrin (around the clock-scheduled doses; every 4 hrs for tylenol, every 6 hrs for motrin, essentially giving something every 3 hrs) -Clear liquids (can be popsicle or water/juice) for 2-3 hrs, then progress diet; want to assess their swallowing, with oral surgeries want to avoid red/orange fluids b/c it can look like blood; might want to avoid milk products b/c can make pt feel nauseous if blood mixes with milk in stomach -Usually outpatient (scheduled procedure, goes home a few hours after surgery. -D/C teaching: pain management, bleeding, foods -Teach pt signs of bleeding: up to a week after a procedure can still have bleeding; signs of bleeding: frequent swallowing, kids don't recognize taste of blood (metal taste); feel it dripping down throat, stomach ache/nausea. Soft foods! No straws!

Bronchiolitis (respiratory illness)

-Inflammation of bronchioles -Cause: RSV (respiratory syncytial virus), parainfluenza; *Important issue because this is the MOST FREQUENT cause of hospitalization in children less than 1 yr old -Signs and symptoms: congestion, coughing, wheezing, tachypnea ( >70), retractions, poor breath sounds -Treatment: humidified oxygen, nasal suctioning (bulb syringe or with nasal catheter), IV fluids, nebulized albuterol (no steroids) -Nursing: Monitoring respiratory status, monitoring O2 sat and maintaining humidified oxygen on patient, I&Os, maintaining IV fluids, teaching parents bulb syringing, maintaining droplet precuations (per CDC) Notes: -Can have bronchiolitis that is not RSV positive -Usually starts as a cold, but then so much mucous/congestion unable to eat or drink so have dehydration. Some have respiratory distress as well; causes difficulty eating and breathing -Treatment: in hospital setting if maintaining O2 sat above 93% w/o oxygen they probably don't need oxygen or humidified oxygen. Below that O2 sat, usually put on Nasal cannula -Blow by: humidified room air blowing by patient's face, or humidified oxygen blow by is only used if they're maintaining their O2 sat fairly well (like 91-92%) -Nasal cannula w/ humidification -nasal suctioning so child can breathe better -Usually suction before eating (sometimes put NS in nose first to loosen up congestion before suctioning) b/c child can eat better after clearing the congestion -No steroids, albuterol also not shown to help -Assessing to see if they need O2 or if they need humidification -Watching I&Os because at risk for dehydration, teach parents how to bulb syringe -Maintaining droplet precautions according to CDC (but some facilities just use contact precautions) -To test for RSV is a swab deep in back of throat (need aspirate), but can have bronchiolitis and be RSV negative

Hydrocele (GU disorder)

-Is fluid in the scrotum (painless scrotal swelling) -Common in newborns, but can occur in an older child *Can be "communicating":* meaning a channel between the scrotum and the abdomen did not close during fetal development: -Change size with straining -Treated with surgical closure by 1 yr of age if it does not spontaneously correct itself: -Teaching: outpatient surgery, site may have swelling/bruising after, avoid straddle toys for 1 month. Leave dressing on for 3 days, may bathe after dressing is removed *Can be "noncommunicating":* meaning they occurred due to trauma, infection, or tumor: -Do not change size with straining Notes: -While it occurs most in newborn males, it can also occur in males of any age. -Sometimes the hydrocele is from an open channel between the scrotum and the abdomen that did not close during fetal development, and a male with an open channel would have more or less fluid in the scrotum depending on how much straining he was doing at that moment. -. If an open channel is present, generally it is given up to 1 year to close on its own. If it does not close, it is surgically closed -If a male has a hydrocele that is non-communicating, there is usually a reason for this sudden increase of fluid in the scrotum and a healthcare provider should consider performing an ultrasound of the scrotum to look for infection or tumor of the testes, or ask about a recent trauma to the scrotum. -might shine a flashlight through the scrotum to make sure it's a hydrocele (will see the light through it) have to differentiate because could also be due to intestines looping down into scrotum

Nephrotic Syndrome/Minimal change Nephrotic Syndrome (GU disorder)

-MCNS is most common type -Typically occurs in males 2-7 yrs -Can have many different causes (metabolic, biochemical, immune), but all lead to same issue: *glomerular membrane is permeable to proteins (albumin)*: -Albumin is lost in the urine (hyperalbuminuria) -Serum albumin is decreased (hypoalbuminemia) -Fluid shifts from the plasma to the interstitial spaces: hypovolemia, ascites *Diagnosis:* -Suspected based on clinical manifestations -Generalized edema (develops gradually or rapidly)- usually the reason for seeking care -Proteinuria 3+ or 4+ on dipstick testing (normally should be none to 1+) -Hypoalbuminemia (is leaking out of kidneys) -Hypercholesterolemia (not well understood why) -Low serum protein and sodium (are being lost in urine) Notes: -Nephrotic syndrome (also called Minimal Change Nephrotic Syndrome just to confuse you) is another genitourinary issue that typically occurs in young males (but it can occur in females too). -Nephrotic syndrome can have a few different causes, but the pathophysiology of what happens in the kidney is the same regardless of the cause: the glomerular membrane becomes permeable to proteins- specifically, albumin. -The problem with the glomerular membrane becoming permeable to albumin is that this protein (which is usually not excreted by the kidney but rather kept in the vascular system) is important in the osmotic gradient of fluid in the circulatory system. If albumin is excreted by the kidney, then there is less albumin in the circulating blood, and so fluid moves from the blood vessels and into the interstitial space between cells (causing hypovolemia in the vascular system and visible edema/ascities). -This is diagnosed first on the visible edema a patient has, then on the large amount of protein in the urine, along with hypoalbuminemia (abnormally low level of albumin in blood)

Nursing care in Nephrotic Syndrome

-Monitoring fluid/edema: assessment of edema, I&Os, daily weights, daily abdominal girth -Infection risk with steroids (or immune suppressants, if treating for relapse): vital signs, handwashing -Children will self-select activities per comfortable activity level -Monitoring for urine protein Notes: -Nursing care of the child hospitalized for nephrotic syndrome includes monitoring intake and output (some may be on fluid restrictions), monitoring edema, assessing a daily weight, assessing a daily abdominal girth, educating the family about the infection risk with long term steroids (good handwashing), and monitoring urine protein (should drop to 2+ or 1+ level- this shows improvement of the disease).

Acute Poststreptococcal Glomerulonephritis

-Occurs after streptococcal infection by strains of group A Beta-hemolytic streptococcus (GABHS)- from either pharyngitis or impetigo *Immune complexes occlude the glomerular basement membrane, decreasing filtration: -RBCs are leaked (hematuria) -Excess water & sodium in plasma & interstitial fluid, -Edema & hypertension (But BP is VERY increased- may have renin involvement) -Latent period of 10-21 days between the infection and onset of manifestations *Can occur at any age: -Most common in 6-7 yr olds -Uncommon in children younger than 2 yrs -More common in boys (2:1) Notes: -This disease happens after an infection with group A beta hemolytic strep, either from strep throat, impetigo, or scarlet fever. -The pathophysiology is that immune complexes from the strep infection occlude the glomerular basement membrane, decreasing the kidney urine filtration. -Because of the damage to the basement membrane, RBC's are leaked, so the urine can have hematuria, but then water and sodium are not filtrated out in the urine (they are kept in the circulating blood volume) so the patient can have edema (not as severe as with nephrotic syndrome) and hypertension (very severe hypertension). *Kidney infection we worry about post strep

Pyloric Stenosis

-Pyloric Sphincter hypertrophies leading to dilation of the stomach with hyperperistalsis and projectile vomiting -Occurs at 2-10 weeks of age -Cause is unknown -Diagnosis: 'olivelike' mass palpated in stomach. Vomiting occurs 30-60 min after feeding. Can also do ultrasound and upper GI x-ray -Treatment: laparoscopic surgical pyloromyotomy. PO clear liquids are resumed 4-6 hrs after surgery, with formula 24 hrs post surgery *Nursing care pre & post op: I&Os, assessing daily weight, assessing for dehydration -Post op: pain control, assessing laparoscopic site for healing Notes: -Pyloric stenosis is a GI condition where the muscle of the pyloric sphincter (that connects the stomach to the intestines) becomes hypertrophic, leading to a narrowed or totally obstructed channel between the stomach and the intestine. -This condition usually occurs in young infants age 2-10 weeks old, and has an unknown cause. *Signs and Symptoms:* -Vomiting during feeds or up to a few hours after, and this vomiting may be projectile -Child will be hungry immediately after vomiting, but may lose weight and show signs of deydration (because they are vomiting up all the calories and fluid that they are being given) -On palpation, a small olive-like mass may be felt in the abdomen, and the diagnosis is confirmed on ultrasound of the pyloric sphincter -Treatment is a surgical pylormyotomy to open the sphincter again. Surgery may be performed in 24-48 hours after diagnosis if the child is dehydrated (so that they can receive fluids and hydration first) or may be performed immediately in a child without dehydration (in this case, the child will be NPO and will receive IV fluids). -Feedings are begun 4-6 hours after surgery, starting with clear liquids and then moving to formula or breastmilk. It usually takes about 48 hours for a child to be eating their usual fluid (formula or breastmilk) and in the usual quantities. Post-operative vomiting is common, so strict I and O's are maintained, and fluid losses are made up via IV fluid. -Pain should be assessed regularly and controlled with pain medications (IV initially, then moving to PO or rectal medication). -*NOT congenital!!* -Cardinal sign is projectile vomiting -When pyloric sphincter enlarges (hypertrophies) nothing can get through

Vesicoureteral Reflux (VUR) (GU disorder)

-Reflux of urine from the bladder back into the ureters: urine becomes reservoir for bacterial growth until next void -More likely to be associated with pyelonephritis (kidney infection) *Diagnosis:* -Signs&symptoms (reoccurring pyelonephritis) -Voiding cystourethogram (VCUG) with contrast into the bladder via a catheter *Treatment:* -Daily Prophylactic low dose antibiotics -Check urine culture q 2-3 months or anytime child has a fever Notes: -Pyelonephritis (which is an infection of the kidney) can be caused by vesicoureteral reflux, which occurs when urine refluxes from the bladder back into the ureters (which, as you remember, descend from the kidneys to deposit urine in the bladder). -Signs and symptoms of VUR occurring are frequent upper tract UTI symptoms (so fever, chills, abdominal pain, vomiting, anorexia, fatigue). -VUR is diagnosed on a voiding cystourethrogram, which is done when a catheter inserted into the bladder deposits contrast into the bladder, and then an MRI watches to see where the contrast goes. -Treatment for VUR is daily low dose antibiotics with urine cultures every 2-3 months, or when the child has a fever or other possible UTI symptoms.

Croup Syndromes: Epiglottitis (respiratory illness)

-Risk for supraglottic obstruction -Cause: usually H. influenza bacteria (Hib vaccine can prevent epiglottitis) -Signs and symptoms: rapid onset (12-24 hrs), sore throat, pain with swallowing, fever, positioning for air hunger (tripod positioning, nose up in the air); *drooling, red, edematous epiglottis-bad signs* -risk of swelling of epiglottis (flap that covers trachea when swallowing) -Diagnosis: on visualization of the epiglottis (sometimes with a scope), or on a chest/neck x-ray after intubation, throat culture -Treatment: MD only visualizes epiglottis (not nurses), humidified oxygen, possibly intubation or tracheostomy, IV antibiotics Nursing Interventions: Monitor RR, respiratory assessment, O2 saturation, keep intubation/tracheostomy supplies at bedside, droplet precautions, mantain IV line, recommend contacts younger than 4 yrs old be treated with rifampin x 4 days -Prevention by Hib vaccine at 2 mo, 4 mo, 6 mo, 12 mo Notes: -If patient comes in with respiratory failure treat it first, then treat epiglottitis, treat respiratory failure first -Emergency treatment: if airway is too swollen for a tube, willl do a trach (make sure tracheostomy set at bedside in case)

Play & Developing Self Concept (School Age Kid)

-School-age play involves physical skill, intellectual skill, rules & rituals -team play is important for teaching group goals & division of labor, also gives sense of belonging with rules & teammates -Quiet, solitary activities usually consist of collecting items and creative skills *Self-concept develops in these years (perception of abilities, values, appearances):* -Significant adults help child shape this (parents first, then teachers, then coaches, church leaders) -Positive self-concept leads to feelings of self-respect, self-confidence & happiness Notes: -organized sports; teams -creative thinking, computer games (talking through headsets, or working with others in video games) -other adults in life become super influential

Acute Streptococcal Pharyngitis (respiratory illness)

-Strep throat! -Infection by GABHS: droplet precautions if in hospital Why do we care about GABHS? -This strep can travel from pharynx to other areas of your body -Risk for Rheumatic fever/heart disease (strep travels and causes damage to heart) -Risk for post-streptococcal glomerulonephritis (strep goes to kidneys and causes infection) -Signs and symptoms: sore, red throat, fever -Diagnosis: Culture (rapid strep test sent for reflex culture, but rapid tests have a high rate of false negatives- tells them they don't have strep when they actually do) -Treatment: antibiotics (Penicillins/amoxicillins) -Infectious until on antibiotics for 24 hrs -Nursing interventions: warm water gargles, tylenol/motrin, cool drinks, soft foods, cold foods, increase fluids

Intussusception

-Telescoping of the intestines, leading to risk of intestinal ischemia due to blood supply being cut off -Intussusception is the most common cause of intestinal obstruction in 5 mo-3 yr old children *Signs & Symptoms:* -Sudden onset of pain w/ fever, vomiting, and red current jelly-like stool with palpable mass *Diagnosis:* -Ultrasound *Treatment:* -IVF, NG to suction, and air or saline enema -20% of patients do not respond to air enema and require surgery: Necrotic area may be removed -Passage of brown stool indicates resolution -Assess for bowel sounds & stool pattern Notes: -Occurs when the intestine 'telescopes' or 'folds' into itself, pulling the mesentery (with arteries and veins) around the intestines with it. The folding of the mesentery with the intestines leads to first venous obstruction, then edema in the area, and eventual obstruction of the arteries giving blood to the intestines. The stopped blood flow causes ischemia of the intestines, and the edema causes blood to leak into the intestines (causing red currant jelly-like stool). Perforation of the intestines may occur. -Signs of intussusception are abdominal pain & blood stools, though children can also have diarrhea, anorexia, occasional vomiting, and only periods of pain (not constant pain). -Intussusception is diagnosed on ultrasound, and is typically initially treated with a radiology guided air or saline enema (to attempt to un-telescope the intestines). If the enema is not successful, the child may have surgery to un-telescope the site (or surgery may also be performed if the area perforated or if there is necrotic tissue present). -Pre-operative nursing care includes NPO status, strict I/O's, IV fluid (and possibly IV antibiotics for perforations), and NGT placement with low suction. -Post-operative nursing care consists of the same, but also assessing bowel sounds, assessing for pain, assessing the incision site, and assessing stool patterns. The child will be given clear liquids first, then slowly transitioned to a regular diet as tolerated. -Can be life threatening -can cut off blood supply to that area so it can become ischemic and then necrotic -Typically affects infants and toddlers -Cardinal sign: red current jelly-like stools -if necrotic area need it to be surgical removed, sometimes colostomy needed temporarily, but other times they are able to reconnect the other areas with no problem

Cleft Lip & Palate

-This most common birth defect, affects 1:600 -Congenital anomaly with an opening either through the upper lip to base of the nose, or an opening between the roof of the mouth and nasal cavity -Unilateral or bilateral -Can have feeding issues, ear infections, speech/language delay, dental issues -Diagnosis: clinical exam or ultrasound Notes: -Cleft lip and cleft palate are the most common facial malformation that children are born with, and they can occur separately (having either a cleft lip, or a cleft palate) or together (having a cleft lip connecting to a cleft palate) -During pregnancy, exposure to alcohol, cigarette smoke, anti-seizure meds, steroids, and low folate levels have been associated with an increased risk of having a cleft lip or cleft palate -Occasionally a cleft lip/palate is found on a natal ultrasound (after 16 weeks gestation), but most are diagnosed after birth when the cleft lip is seen and the cleft palate is felt (by a provider's gloved pinky finger) *Cleft Lip and Palate Surgical Repair:* -Lip surgical repair done at 10-12 lbs -Palate surgical repair done between 9-12 months (before speech) *Nursing issues prior to surgery are feeding an infant with a cleft palate: -Multiple types of nipples: Haberman is most well known, nursing/OT/SLP work with parents/caregivers -Early interventions involved for speech, swallow issues *Nursing issues after surgery are allowing the site to heal *What do you think some of the post op nursing interventions are?* -Side lying or sitting up for secretion management -Humidified air for edema at oral mucosa -No oral suctioning due to sutures -No straws, spoons, thermometers (to protect sutures/incision sites) -Elbow restraints ('welcome sleeves'-to protect sutures/incision sites) -Pain management -Assessment of site for bleeding or infection Notes: -Treatment is by surgery to repair the cleft(s), with repair of the lip taking place around 2-3 months, and platelet repair around 1 yr (to prevent speech issues) *Pre-surgically if the cleft interferes with breast feeding, the child will be fed PO using adaptive nipples (typically a speech language pathologist or occupational therapist will select the appropriate nipple for the child and educate the parent on its use, however, the nurse should support family use of the nipple) -Due to the cleft, infants can drink in more air than infants without clefts, so educating parents on the importance of burping is important *Post surgical Nursing Care:* -Focused on maintaining the surgical site (using elbow restraints/welcome sleeves so the child cannot touch the site, but giving frequent supervised breaks from this restraint; not using oral suction, straws, spoons, or oral thermometers) -Additional nursing care includes pain management, assessment of the incision site, and humidified room air to decrease oral edema -Usually the child resumes the feeding method used before surgery, and is slowly transitioned to normal nipples or cups -If an older child has a palate repair, the child should have a soft diet for up to a week post-surgery, to let the incision site heal -Post surgically, some children need speech therapy to support verbal articulation *infant with cleft palate can not usually breast feed

Genitourinary Dysfunction:UTI

-UTI: they occur in kids too! 10% have febrile UTI between age 0-2 *Upper tract infection:* Ureters & kidney (fever, chills) -Pyelonephritis -Vesicoureteral reflux (VUR) -Glomerulonephritis *Lower Tract Infection:* Bladder & Urethra (typically asymptomatic -Cystitis -Urethritis *Pathophysiology:* -Urinary stasis (voiding 'flushes' the urethra of bacteria) -Shorter urethera in girls -Uncircumcised males Notes: -UTI's as you remember are divided into either upper tract infections or lower tract infections, and in general in children the upper tract infections have characteristic signs and symptoms, while lower tract infections have either no symptoms or non-specific symptoms (irritability, abdominal pain). -Causes of UTI in children are 'holding' urine (because this allows bacteria time to grow), girls having a short urethra that bacteria can get into and then move up into the bladder, and males who are uncircumcised have a higher risk of UTI's compared to circumcised males. -symptoms: fever. vomiting, don't always have the back pain that adults typically do

Mononucleosis (Respiratory illness)

-Viral (CMV, toxoplasmosis, Rubella, adenovirus); Most commonly caused by Epstein-Barr Virus (EBV) which is one of the herpes viruses; 1 out of 4 infected with EBV will develop mononucleosis -Spread via body fluids (saliva), prevention is not sharing drinks, foods; standard precautions -Signs and symptoms: extreme fatigue, fever, sore throat, body aches, swollen axillary/cervical lymph nodes, possibly enlarged liver and/or spleen -Signs & symptoms can begin 10 days to 6 weeks after exposure (average incubation 4-6 weeks; long incubation period); acute symptoms last 7-10 days, fatigue lasts 2-4 weeks, but can be 2-3 months before feel normal -Diagnosis: monospot for antibodies, WBC, LFT's; Labs on pts to determine if liver is enlarged or spleen is enlarged -Treatment: fluids, rest, OTC ibuprofen for pain/fever; antibiotics if GABHS -can technically get mono more than once b/c can be caused by dif viruses

Croup Syndromes: Laryngotracheobronchitis (respiratory illness)

-Viral causes (RSV, influenza, parainfluenza) -Signs & symptoms: Upper respiratory infection which descends, *barky brassy cough*, low grade fever, air hunger (nasal flaring, tachypnea, inspiratory stridor and retractions- due to tracheal narrowing) *Treatment:* -*Minor (no stridor):* can be managed at home, teach parents signs and symptoms of respiratory distress, cool air vaporizer; teach parents to look for worsening signs: if stridor develops take kids to hospital, retractions (pulling) teach them to look at chest and if see outline of bones it is a worrying thing, cool air humidifier/vaporizer can help. Tylenol for child comfort; probably not eating as well so look for dehydration -*More than minor:* W/ stridor immediately sent to emergency department/inpatient care with saline nebulizer, racemic epinephrine (decreases edema; nebulizer to open up airway), IM dexamethasone or PO steroids, maybe nebulized steroid -*Nursing Interventions:* Monitor respiratory status, keep on oxygen saturation monitoring, administer nebulizers (know what meds are available and when they are due- epinephrine, steroids, saline nebulizers), monitor PO fluids and initiate IV fluids if needed; monitor I&Os- measure diapers

Otitis Media (respiratory illness)

-ear infection! -Infection/inflammation of middle ear -Risks: Upper respiratory infection, exposure to cigarette smoke, age (common in younger children b/c of short, straight eustachian tubes) -Signs & symptoms: irritable/fussy, upper respiratory infection, fever, pulling ears (b/c they hurt) -Diagnosis: Clinical exam (red, edematous tympanic membrane); diagnosed visually using an otoscope to look at tympanic membranes (red, edematous); a healthy tympanic membrane is usually pink/gray, kind of translucent -Usually bacterial (even though we don't culture) so we use antibiotics b/c long term risk of hearing loss so we treat it *Treatment:* -Treatment based on age of child and severity of illness -Less than 6 months: antibiotics (amoxicillin); immune system isn't good yet so def treating with antibiotics -6 months and up: watchful waiting; have parents come back every 2-3 days, if it gets worse/not getting better then we'l treat with antibiotics -If severe illness < 6 yrs: antibiotics 10 days (a bilateral ear infection or having a fever over 101 is considered a severe illness) -If severe illness > 6 yrs: antibiotics 5-7 days -Nursing intervention: tylenol/motrin, tell parents to watch for nasal congestion and other symptoms *Surgical Treatment:* -For prevention of hearing loss that is associated with chronic otitis media (scarring on tympanic membrane from recurrent otitis media makes it thicker, so tympanic membrane doesn't transmit sound as well, can create conductive hearing loss) -*Myringotomy:* incision in tympanic membrane and applying topical antibiotics; can be done without tubes, esp. if kid has constant fluid in ears, so not infections, but creates hearing loss (nursing intervention: applying topical antibiotics) -*Tympanostomy tubes:* tubes fall out on their own eventually, hopefully after at least a year, sometimes they fall out before and it is up to surgeon whether new ones are placed or not -Use ear plugs for swimming, caution getting shampoo in ears *Can be separate procedures

Why are respiratory illnesses such an issue in children?

1. Shorter, straight eustachian tubes, large tonsillar and adenoid tissue: -bacteria/viruses sit in eustachian tubes (where it is warm and moist so they rapidly replicate), cause upper respiratory infections and ear infections; as you get older eustachian tubes slope down so there is more drainage -Large tonsillar/adenoid tissue: can swell and impact airway 2. Smaller, narrower, under developed trachea: more easily obstructed 3. Increased oxygen consumption: fewer alveoli to perform gas exchange (50 million vs 300 million) *Respiratory Assessment:* -Look: symmetrical, nasal flaring, circumoral cyanosis, retractions ('pulling'), oxygen saturation; Retractions: suprasternal, intercostal (between ribs), subcostal, substernal (below xyphoid process) -Listen: Nasal congestion, cough (productive or not?), lung sounds (both anterior and posterior and right middle lobe); any audible wheezing w/o stethoscope -Feel: RR *Respiratory disorders are a huge reason for hospitalizations and sick visits in children

Hirschsprung Disease

Absence of ganglion cells in the walls of a variable segment of rectum and colon: -The absence of ganglion cells prevents peristalsis at that portion of the intestine -Mechanical obstruction from inadequate motility of the intestine -Because stool cannot move forward normally, the intestine can become partially or completely obstructed, and it begins to expand -The problems a child will experience with Hirschsprung disease depends on how much of the intestine has normal nerve cells *Signs and symptoms:* -No bowel movement in the 1st 48 hrs of life (cardinal sign) -Failure to Thrive: maybe infant is not eating enough to cause a stool -Constipation that worsens with time -Delayed growth -Ribbon like stools -Visible peristalsis in abdomen: b/c stool is backed up and muscles are working really hard to push stool forward through intestines, but not working well *Treatment:* -Diet/stool softeners (short segment) -Surgical (long segment) Notes: -Hirschsprung disease is a congenital (born with it can't acquire it later on) disorder where the child is born without ganglion nerves in the bottom segment of the colon and rectum. -The absence of the nerves means that peristalsis cannot occur in that area, so stool can become stagnant here, leading to constipation and bowel obstruction. (prevents peristalsis in lower colon so baby is not pooping) -In a normal colon the internal sphincter relaxes due to stool being present; this relaxation does not occur in Hirschsprung disease,leading to constipation and impaction. -If there is any impaction, the child is at risk for megacolon, as stool backs up in the aganglionic segment and causes expansion of the intestine *Signs and symptoms:* -No bowel movement in 1st 48 hrs of life (only 10% of those with Hirschsprung have a BM soon after birth) -Distended abdomen -Feeding intolerance with bilious vomiting *Diagnosis of Hirschsprung is on rectal biopsy for assessment of ganglion cells* -The degree of constipation that a child has and their risk for megacolon depends on how much of the intestine has normal cells. -If most of the intestines has the proper ganglion cells (80% of Hirschsprung cases only affect the internal sphincter, rectum, and a few centimeters of the sigmoid colon), then the child may only need bowel support similar to constipation (stool softeners and enemas). -For children who require surgery, the amount of bowel distention present determines if a temporary colostomy will be needed *Nursing Care at Diagnosis:* -Consists of educating the parents about the diagnosis and most likely medical treatment plan, as well as fostering the infant-parent bond. -Pre-operative nursing care consists of enemas to cleanse the bowel and either IV antibiotics or colon antibiotic irrigations. -Since pre-operative bowel perforation is a possibility, the bowel size should be measured q shift over the umbilicus -Post operatively: children are assessed for bowel regularity, nutrition tolerance, and wound healing *Some are managed with diet (fiber) and stool softeners, others need removal of that area of the colon

Piaget's Cognitive Development: School Age Kids

Ages 6-12 yrs includes: -Preoperational: 2-7 yrs -Concrete operations: 7-11 yrs -Formal Operations: age 11-15 yrs *Concrete operations is the stage most associated with school age children:* -Use thought processes to experience events and actions -Develop an understanding of relationships between things and ideas -Perceptual thinking progresses to conceptual thinking: from making judgements based on what is seen to making judgements based on what is reasoned (conservation skills & classification skills/collecting) -Conservation skills: good ex in txtbook: analytical reasoning. Same amount of water in two glasses that look different. Is it the same amount of water? -Classification skills: grouping/collecting things (collections are really common in this age)

Cardiovascular Dysfunction

Congenital Heart Disease (CHD) = congenital anomalies (congenital means they are born with it) -Incidence is 5-8 in 1,000 births, ventricular septal defect is most common Why do these occur? -genetic (10-12%),family history, Trisomy 21, Turner Syndrome (some genetic disorders linked closely to congenital heart disease ex. trisomy 21 linked to ventricular septal defect); -Maternal or environmental cause (1-2%), Diabetes, Lupus, Alcohol, medications -Multifactoral (85%) How are these diagnosed? -In utero can be diagnosed by ultrasound (but doesn't always catch them) -Assess a newborn: heart sounds, any murmur in a baby we don't freak out right away but we follow it. O2 sat (CCHD screening, uses O2 sat on infants hand and foot if there is a 3% difference or more, have to rescreen them), circulation (perfusion, color, pulses) -Abnormal assessment findings then leads to EKG, echocardiogram, cardiac catheterization -EKG/ECG measures the electrical activity of the heart -Echocardiography shows an image of the heart & its current function -Cardiac catheterization leads a catheter into the heart to measure pressures & oxygen saturation. MRI imaging shows where the catheter is: -Cardiac cath can diagnose & treat issues. Risks are arrhythmias, renal issues from contrast, & injury to heart endothelium -Pre procedure care: height, weight, allergy, signs & symptoms of infection, pulses, O2 sat, prep for sedation (NPO prior) -need to know weight in order to know how much for more meds and fluids -Post procedure care: pulses, CSM (circulation, sensation, movement) of extremity used, BP, dressing on site, intake, keep limb straight & dressing clean and dry -Cardiac cath usually uses femoral artery, big risk post procedure is bleeding, usually put pressure above the dressing to stop bleeding at the artery, want to keep the limb that was used straight (to increase clotting at site)

Sexual Maturation (adolescents)

Full sexual maturity takes time: -18 months to 6 yrs for girls -2 to 5 yrs for boys Tanner stages of sexual maturity: -stages of development of secondary sex characteristics and genital development (Appear in an orderly fashion) -Defined as a guide for estimating sexual maturity -(Sequence of sexual maturity box 15-2 pg 450) -Linear growth accompanies sexual maturation *Adolescent growth spurt:* -20-25% of total height is achieved during puberty -usually occurs within a 24-36 month period -Girls grow between 9.5-14.5 yrs -Boys grow between 10.5-16 yrs -Growth ceases 2 yrs after menarche in girls or at age 20 in boys Notes: -assess the child and then look at these tanner stage charts to compare the child too to determine what stage they're in; just be aware of them, but on exams she won't make you pick which one for a question

Encopresis (School aged kids)

Repeated voluntary or involuntary passage of feces of normal or near normal consistency into places not appropriate for that purpose: -must occur once per month x3 months, in a child of a chronologic or developmental age over 4 -Not caused by any physiologic effect (e.g. laxative or medical problem) -Primary encopresis is a child 4 yrs old who has never acheived fecal continence -Secondary encopresis is fecal incontinence after a period of prior established fecal continence after age 4 yrs -May follow psychological stress: a change in the structure or routine of the child, or of environmental change (house, school) -May be secondary to constipation or impaction *Therapeutic Management:* -Determine the cause (KUB for constipation) -Dietary intervention; management of constipation -Psychotherapeutic interventions *Treatment:* -Toileting routine: 10-15 minutes on the toilet after meals -Nutritional changes: Increased fiber and fluids -Stool softeners: high doses needed -Usually due to kids not toileting well, not having good toilet habits or poor nutrition

Congenital anomaly diagnosis & family care

What are priority points in the care of the family when an anomaly is diagnosed? -Education of what the defect is, how it was caused, treatment What are priority points in the care of the child with an unrepaired cardiac anomaly? -Monitoring for signs of heart failure -Assessing physical growth (infants can have difficulty eating- don't eat as much, don't gain weight or grow length wise as well either) -Assessing for developmental delay -Promoting immunizations (around surgeries), synagis vaccine (august to march against RSV) If a child is to receive a cardiac catheterization, what pre & post assessments is the nurse responsible for? -Pre: bilateral peripheral pulses, warmth of extremities, BP, fluid status -Post: bilateral peripheral pulses, warmth of extremities, BP, fluid status, dressing, keep limb straight What teaching is important for the family after a catheterization? -Effects of catheterization: nausea, vomiting, risk of hemorrhage -Other teaching: avoid tub baths x 3 days, watch the site for bleeding, redness, swelling, drainage, remove the bandage the next day, but keep bandaid on insertion site, if bleeding occurs apply pressure 2 inches above insertion site Notes: -can't always pick up these defects in utero, so it totally changes the picture when we find out after birth, very scary, parents feel unprepared, worried -Any anomaly in heart can put pt at risk for heart failure (so educate parents on when to worry- signs/symptoms of HF) -Synagis: prevents RSV infection; usually started in august and given til march, not really a vaccine because it is antibodies that die within 30-60 days -Educate about signs and symptoms of bleeding, avoid tub baths for about 3 days (b/c risk of infection)

Kawasaki Disease (cardiac disorder)

What is the pathophysioogy of the disease? -Vasculitis of unknown cause leading to clot formation in blood vessels -Risk of coronary artery aneurysms or acute myocardial infarction *Three Phases:* 1. Acute phase: sudden high fever that is unresponsive to antipyretics and antibiotics; child is irritable 2. Subacute phase: Lasts from the end of fever through the end of all kawasaki disease clinical signs 3. Covalescent phase: clinical signs have resolved, but platelet values have not returned to normal, ends when normal values have returned (6-8 weeks) *What are the signs & symptoms of the disease?* -Fever > 5 days with 4 or 5 clinical criteria: 1. erythema of the palms and soles or desquamation of the hands and feet, 2. bilateral conjunctival injection (if pulldown lower eyelids and conjunctiva is super red), 2. erythema of the lips or strawberry tongue, 4. rash, 5. cervical lymphadenopathy *How is the disease diagnosed?* -Diagnosed: Signs & symptoms or can have 'alternate' presentation (watch any child with a long term high temp that does not respond to antibiotics and has no other cause Notes: -general vasculitis (inflammation/infection of the vascular system) no known cause- think it is immune -If it does happen it can lead to clot formation in heart and blood vessels -risk of coronary artery aneurysms, ischemia, and acute MI -high fever, and infection isn't found in urine sample or CBC -Kawasaki disease is typically diagnosed based on symptoms, but sometimes providers diagnose it as suspect or atypical kawasaki if they don't have all of them b/c they don't want to miss it *How is disease treated?* -Treatment: acetylsaliculic acid (ASA) 80-100 mg/kg/day for fever (Aspirin is generally not recommended for children but OK with Rheumatic fever and kawasaki disease -Intravenous gamma globulin (IVGG) aka IVIG (immune globulin): best outcome if given in first 10 days of disease onset -Then 3-5 mg/kg/day ASA antiplatelet therapy *What is nursing care for this disease?* -Monitor I&Os, daily weights, tachycardia, respiratory distress -Long term: those with aneurysms are seen by cardiology for monitoring of cardiac status: risk for myocardial infarctions, teach pt CPR & signs/symptoms of MI; may need long term antiplatelet therapy if aneurysms, BP monitoring, arthritis (joint pain) can last for 1-2 months, irritability can last for 2 months and can be an issue Notes: -IVIG/IVGG is antibodies given to try and chill out the immune system -want to prevent long term cardiac issues -long term issues are aneurysms and MI- send them to cardiology for monitoring

Atrial Septal Defect (ASD) (Increased pulmonary flow defect)

Where is the defect located in the heart? -Between the Left and Right atria What is the effect on blood flow? -More blood goes to the right atria What type of defect is this? -Increased pulmonary flow What would signs and symptoms be? -Usually asymptomatic, may develop HF, may have murmur Is there any treatment? -Surgical repair for moderate or large defects Notes: -Same as VSD but between the atria now -Left side of the heart always has higher pressure than the right, so blood goes high to low toward the right atria -B/c the left atria has higher pressure than the right atria, blood is going to go to the right atria, but pressure in the atria is lesser than that in the ventricle so it's usually asymptomatic (b/c dif between pressure isn't as significant as with ventricles, so not as much blood)

Ventricular Septal Defect (increased pulmonary flow defect)

Where is the defect located in the heart? -Between the Left and Right ventricles What is the effect on blood flow? -More blood goes to the right ventricle What type of defect is this? -Increased Pulmonary flow What would signs and symptoms be? -Heart failure is common, may have murmur Is there any treatment? -Up to 60% close on their own -Large defects need repair Notes: -Hole between the septum between L & R ventricles -Effect on blood flow: LV is the work horse of the heart, highest pressure is in the LV, blood likes to go from high pressure to low pressure, so it moves from the LV to the RV, so the blood goes toward the right and then ends up in the lungs -Increased pulmonary flow defect (b/c it leads to more blood in the lungs) -Will see crackles, O2 sat will probably stay the same, could have back up of blood in the lungs, if the hole is big enough can lead to HF -May have a murmur (murmur usually just means person has turbulent blood flow in the heart, so whether there is one or not depends on the size of the hole) -Usually just monitor to see if it closes on its own, if large need reapair

Coarctation of the Aorta (Obstruction of blood flow out of the heart/Obstructive defect)

Where is the defect located in the heart? -In the aorta, after the head/neck/arms vessels What is the effect on blood flow? -Less blood going through the narrowed area in the aorta, blood backs up into head/neck/arms vessels What type of defect is this? -Obstruction of blood flow out of the heart/obstructive What would signs and symptoms be? -Higher BP & stronger pulses in arms compared to legs, HF in infants if very narrowed, dizziness, headaches & syncope in older children d/t hypertension Is there any treatment? -Balloon angioplasty initially, or surgical anastomosis if long segment. Residual hypertension may occur if fixed after child is 2 Notes: -coarctation: pinch of the aorta -Almost always after the aortic branch that takes blood to the head/neck.arm vessels -The pinch is like a tollbooth, cars back up before the toll booth, but then it's pretty easy moving but not a lot after the toll booth (so a lot of blood backed up in the head/neck/arms, but then not as much in the lower body) -Blood is obstructed leaving the heart -Higher BP and stronger pulses in arms compared to legs (b/c more blood flow to the top area -Headaches and syncope are a common side effect (b/c such high BP in head/neck/arms) -Balloon angioplasty initially, or if it is really big they do a surgical anastomosis (cut out coarctation and reattach the two parts)

Aortic Stenosis (obstruction of blood flow out of the heart/obstructive defect)

Where is the defect located in the heart? -In the aortic valve (takes blood from the left venticle to aorta) What is the effect on blood flow? -Less blood leaving left ventricle going to aorta What type of defect is this? Obstruction of blood leaving the heart/obstructive What would signs and symptoms be? -At birth: faint pulses, hypotension, tachycardia -Children: exercise intolerance, chest pain, dizziness with long periods of standing, risk for sudden MI with exercise Is there any treatment? -Balloon angioplasty initially, or surgical valvotomy if angioplasty is unsuccessful (may need replacement in 10 yrs) Notes: -aortic valve is narrowed -less overall circulation, so faint pulses, hypotension, tachycardia (to try and compensate for lack of blood- heart pumps faster to send more blood) -A lot of times when you hear about a child playing sports/exercising and having a cardiac event and passing away it is likely due to aortic stenosis (b/c cardiac arteries come off of the aorta

Pulmonic Stenosis (obstruction of blood flow out of the heart/obstructive defect)

Where is this defect located in the heart? -In the entrance to pulmonary artery (takes blood from right ventricle towards lungs) What is the effect on blood flow? -Less blood leaving right ventricle going to lungs What type of defect is this? -obstruction of blood flow out of the heart/obstructive What would signs and symptoms be? -Can be asymptomatic or have mild cyanosis or heart failure Is there any treatment? -Balloon angioplasty initially or surgical valvotomy if angioplasty is unsuccessful Notes: -blood flow is obstructed leaving the heart -Low O2 sat, cyanosis, could have heart failure with blood backing up in the left side of the heart