NUR 336 Exam 4
What are the 4 types of shock?
- Cardiogenic: damage to heart muscles resulting in inability to pump blood - Hypovolemic: dehydration or blood loss w/ decreased Hgb resulting in hypovolemia - Distributive: shift of fluids from intravascular spaces into the extracellular space due to blood vessel dilation, often result of sepsis or anaphylaxis - Obstructive: something is blocking the path of blood leaving the heart; decreased ability of heart to pump NOT related to cardiac disease (PE, tension pneumothorax, aortic dissection) ** place patient in trendelenberg position for distributive shock
Which disorders are considered increased pulmonary blood flow disorders?
- PDA, ASD, and VSD - these disorders tend to result in pulmonary edema and pulmonary hypertension
UTI: affected parts, cause, s/s, Dx, Tx
- affected parts: urethra, bladder, ureters, renal pelvis, renal calyces, and renal parenchyma - cause: often bacterial, E coli is most common - s/s: fever, vomiting, abdominal/flank/back pain, dysuria, increased urinary frequency and urgency, hematuria, jaundice, poor oral intake/FTT - Dx: Urinalysis showing nitrates, culture (use straight cath unless old enough to comprehend how to do clean catch), voiding cystourethrogram (contract pictured in bladder during void) - Tx: broad spectrum antibiotics until culture and sensitivity come back, IV fluids, promote regular voiding, educate on prevention
what are some nursing consideration for pediatric abdominal assessments?
- auscultate before palpation - assess stool pattern, eating pattern, fam Hx - inspect: body position, abd shape/contour, skin - auscultate: hyperactive sounds can indicate gastroenteritis or lactose intolerance, obstructions will sound like high pitched loud tinkling rushes, paralytic ileus= absence of bowel sounds after 5 minutes - percussion: should hear tympany over stomach, resonance=gas, dull=mass - palpation: feel for tenderness, lumps, and guarding reaction to palpation
GERD: pediatric cause, s/s, complications, interventions
- cause: immaturity of lower esophageal sphincter - s/s: vomiting, burning sensation, choking, delayed weight gain, irritability after feeds, arching back during or after feeds, apnea in infants, chronic cough, chronic pneumonia, epigastric pain, mid-sternal discomfort, sleep interruption, sore throat - complications: poor weight gain, dehydration, aspiration - interventions: hold upright during and after feeds to prevent aspiration, small and frequent and thickened feeds, assess i/o, avoid trigger foods, frequent burping, may require low fiber diet, for older kids its all the same interventions as adults
What are nursing considerations for surgical repair of VSD/ASD?
- completed via cardiac catheterization - femoral pressure dressing to prevent hemorrhage from site - assess catheterized extremity for changes in temp and color that can indicate obstruction of blood flow - watch for cyanosis, poor weight pain, resp distress (may indicate PE), lethargy, and bleeding at insertion site - educate on possible need for antibiotics prior to dental work to prevent endocarditis
Hemolytic Uremic Syndrome (HUS): definition, s/s, electrolyte, Tx
- definition: RBCs are destroyed and block kidney's ability to function normaly; triad cause= microangiopathic hemolytic anemia, thrombocytopenia, AKI after recent illness (e coli) - s/s: occurs 2-12 days after onset of hemorrhagic enterocolitis, bloody diarrhea, pallor, jaundice, oliguria/anuria, HTN, signs of bleeding into tissues, edema, irritability, anorexia, seizures - Electrolytes: high K+, low Na+, low Ca+, hyperphosphatemia - Tx: IV isotonic fluids, blood transfusion, i/o + daily weight, monitor for seizures and mental status changes, dialysis
Volvulus: definition, s/s, Dx, treatment
- definition: abnormal twisting of GI tract that can impair blood flow causing gangrene, necrosis, obstruction, perforation, and peritonitis; usually occurs in the first 6 months of a child's life - s/s: intense crying, pain, guarding stomach by pulling up legs, abdominal distension, bilious vomiting, tachycardia, tachypnea - Dx: series of upper GI x-rays, CBC with electrolytes to look at possible complications - Tx: surgical emergency, NPO, IV therapy, NG tube insertion to prevent vomiting, i/o, prep for surgery, give patient pacifier to satisfy sucking needs without causing vomiting
Hirschsprung's disease: definition, s/s, Dx, treatment
- definition: congenital GI condition where the bottom segment of the colon does not have nerves; this can result in blockage - s/s: no meconium in first 24 hours of life, constipated, bowel movements only 1x/week, ribbon-like watery stool, protuberant abdomen, vomiting, poor weight gain/increased risk for FTT - Dx: digital exam will find empty rectum, progress to x-ray and barium enema, - Tx: enemas frequently to help pass stool, may require surgical removal of affected section of bowel and possible temporary colostomy
Biliary atresia: definition, s/s, Tx
- definition: congenital absence/closure of major bile duct which results in cirrhosis - s/s: significant jaundice at 2 weeks, dark urine, light colored stools, enlarged liver - Tx: Kasai procedure to make new bile duct, IV fluids, low fat high protein, fat soluble vitamin supplementation, liver transplant if Kasai procedure fails
vesicoureteral reflux (VUR): definition, s/s, Dx, Tx
- definition: congenital anatomical abnormality that allows for urine to flow backwards from the bladder into the ureters - s/s: frequent UTIs, suprapubic pain, urinary incontinence, fam Hx, enlarged (palpable) bladder - Dx: urinalysis, culture, US, postvoid cath to check for retained urine, definitive diagnosis is VCUG (voiding cystourethrogram) where dye is injected into the bladder and x-ray pictures dye during void - Tx: antibiotics to treat and/or prevent UTIs, usually resolves on its own around 5 or 6 y/o, if severe, may require surgery, educate parents to monitor i/o at home, if it doesn't resolve and is left long term then it can develop into renal failure
Cleft lip/pallet: definition, interventions/considerations, post-op complication prevention
- definition: craniofacial deformities that occur in utero and are surgically repaired - interventions/considerations: speech therapy consult for feeding difficulties, monitor for aspiration, monitor for ear infections - post-op complication/prevention: children may require soft restraints (no-no's) to prevent them from touching/injuring the suture line
Tetralogy of fallot (TOF): definition, defects included, TET spell definition and teaching, nursing interventions
- definition: cyanotic heart defect resulting in increased blood flow to the left side of the heart which causes deoxygenated blood to recirculate to body - defects: VSD, pulmonary stenosis/obstruction, overriding aorta (connects to both ventricles), right ventricular hypertrophy - TET spell: sudden cyanosis and possible syncope, educate parents that squatting position (knees to chest) can increase blood flow from legs back up to brain - Interventions: cluster care, high calorie feeds, monitor growth/development, sedate to decrease agitation, maintain fluid balance, admin O2, admin prostaglandin E to keep PDA open
Acute Kidney Injury: definition, cause, labs, Tx
- definition: decreased GFR occurring over hours to days resulting in inability to clear blood of urea and regulate the fluid and electrolytes balance - cause: poor kidney perfusion, ischemia, toxicity, nephropathy, sepsis - labs: elevated BUN, elevated creatinine, elevated K+, low Na+, metabolic acidosis, anemia, proteinuria, hematuria, may have abnormal ECG due to electrolyte imbalances - Tx: dialysis to remove fluid if FVO is present, isotonic IV hydration, PRBC transfusion
Gastroenteritis: definition, s/s, rehydration
- definition: diarrhea without chronic disease often caused by a pathogen - s/s: v/d, abdominal cramping, h/a, fever/chills, bloody or pussy stools, dehydration (depressed fontanels, no tears when crying, tachycardia, poor skin turgor, lethargy, oliguria) - rehydration: if signs of dehydration are not present, oral rehydration solution can be given every 30 minutes, if signs of rehydration are present then patient requires IV rehydration with isotonic solution
Celiac disease: definition, s/s, Dx, priority interventions
- definition: hereditary immune disease where body mounts an immune attack on small intestine microvilli when wheat gluten is ingested causing poor nutrient absorption - s/s: bloating, v/d, weight loss, gas, foul smelling stool, delayed growth/development, rash, iron deficiency anemia, B12 deficiency, osteoporosis due to inadequate calcium absorption - Dx: endoscopy w/ biopsy, CBC, immune function blood test to look for high IgA which indicates inflammation - interventions: gluten free diet, consult dietician for resources for family, educate family to follow up regularly with a gastroenterologist
ASD: definition, diagnosis, assessment findings, nursing interventions?
- definition: hole in septum between the atria which would normally close within 4-8 weeks of fetal development stays open which allows more blood to flow from the right atrium into the left atrium, increasing pulmonary blood flow - Diagnosed via Echocardiogram which shows enlarged right side of heart - Assessment findings: heart murmur, atrial dysrhythmias, increased incidence of emboli, SOB, easily fatigued, poor feeding/growth, enlarged right sided heart chambers - interventions: small and frequent feedings while monitoring tolerance, watch for s/s of CHF, prep pt and fam for surgical closure via cardiac catheterization, monitor for grunting, retractions, nasal flaring, and increased WOB, if giving digoxin hold if HR is below 90 and watch potassium levels
ventricular septal defect (VSD): definition, diagnosis, assessment findings
- definition: hole in septum between ventricles resulting in increased blood flow towards left ventricle and then increased pulm blood flow - Diagnosed with echocardiogram which will show enlarged left atrium - assessment findings: often asymptomatic, may have heart murmur upon auscultation, if symptomatic may show SOB, feeding difficulties, systolic thrill palpated in lower left sternal border, FTT, recurrent resp infections due to increased fluid in lungs
Acute Postinfectious Glomerulonephritis: definition, s/s, Tx, eval of Tx
- definition: inflammation of glomeruli in response to preceding illness (often strep URI or skin infection) - s/s: hematuria (dark tea colored urine), proteinuria, oliguria, HTN, peripheral and/or pulmonary edema, anorexia, arthralgia, abdominal pain, malaise - Tx: diuretics, antibiotics, i/o, daily weights, monitor creatinine, kayexalate for high K+, antihypertensives, could require dialysis if kidney function is decreased significantly - evaluation: i/o will show fluid balance, daily weight will go down to baseline, urinary output will go back to normal (1 ml/kg/hr for older kids), creatinine will return to expected range
Appendicitis: definition, s/s, complication, priority interventions
- definition: inflammation of the appendix - s/s: pain in periumbilical area that migrates towards RLQ (McBurney's sign), low grade fever, n/v, guarding, laying with knees bent, obturator sign (pain w/ internal rotation of flexed thigh), iliopsoas sign (pain on extension of right hip), merkels sign (kid jumps and lands on heel causing RLQ pain) - complication: perforation/rupture indicated pain suddenly resolving - priority interventions: NPO, IV hydration, prep for surgery with antibiotics and pain meds
Hypoplastic Left Heart Syndrome (HLHS): definition, s/s, priority nursing interventions, education
- definition: left side of the heart (aorta, aortic valve, left ventricle, and mitral valve) are all underdeveloped which leads to pulmonary and venous congestion/edema: PDA allows oxygenated blood from pulmonary veins to enter aorta - s/s: usually occur when PDA closes, pale/grey/ash colored skin, tachypnea, SOB/dyspnea, poor feeding, fatal within first days or months unless treated - priority intervention: PGE to keep PDA open - education: surgical correction (3 surgeries) or transplant, lifelong cardiologist follow ups and cardiac meds, prophylactic antibiotics to prevent infective endocarditis
Nephrotic syndrome: definition, s/s, complications, Tx
- definition: most common kidney disease in children; often occurring after a URI that damages kidneys - s/s: massive proteinuria (albumin), hypoalbuminemia, gravity dependent edema, hyperlipidemia, hyponatremia, weight gain, protruding abdomen, oliguria, anorexia, easily fatigued, HTN - complication: sudden respiratory distress can indicate pulmonary embolism!!! - Tx: diuretics, antibiotics, O2, corticosteroids, IV albumin, daily weight, abd girth daily
Kawasaki disease: definition, s/s, interventions/considerations
- definition: mucocutaneous lymph node syndrome; inflammation in walls of small and medium sized blood vessels (often coronary arteries); more common in Pacific Islander decedents; can progress into coronary artery aneurysm then MI - s/s: High fever AND 4/5 symptoms (rash on trunk or genitals, enlarged cervical lymph nodes, conjunctivitis, red lips and strawberry tongue, red/swollen/peeling hands and feet); can mimic scarlet fever, can cause diarrhea, abd pain, joint pain, irritability - interventions/considerations: anti-inflammatory meds (high dose aspirin), IV immunoglobulins, watch for CHF, encourage wearing loose clothing, use cool cloths, oral/lip care, soft/tepid foods, may require CPR
Coartation of Aorta (CoA): definition, assessment findings, treatment
- definition: occurs when there is an aortic narrowing between the upper extremities and the lower body, often occurs with VSD and Turner's syndrome (missing or broken X chromosome in females) - s/s: BP will be higher in upper extremities than in the lower extremities by more than 20 (4 point BP is best practice for these kids), pulse will be stronger in upper extremities/decreased femoral pulses, may have HTN, SOB, poor feeding, headache (due to increased ICP), may develop s/s of CHF, right sided HF, 3/E sign with chest x-ray - treatment: balloon dilation, stent placement
Intussusception: definition, s/s, Dx, Tx
- definition: part of the intestine slides into the part next to it, looks like a telescope and can obstruct flow of food and fluids; can also cut of perfusion to affected intestine leading to perforation, infection, and necrosis - s/s: drawing up of legs and crying in pain every 15-20 minutes or at other regular intervals, bilious vomiting, currant-jelly stools containing blood and mucus, palpable "sausage shaped" mass in abdomen, abdominal distension, tenderness and guarding, tachycardia, elevated WBCs and fever indicate perforation - Dx: ultrasound, CBC, barium enema - Tx: NPO, IV fluids, NG tube, barium enema, surgical correction, air insufflation or water soluble solution (blow up intestine like a ballon to push out affected intestine overlap)
Pyloric stenosis: definition, s/s, Dx, treatment
- definition: pylorus is thickened so much that peristalsis cannot force food through stomach into small intestines - s/s: forceful and projectile vomiting after each feed, poor weight gain, dehydration, decreased serum chloride, FTT, can see peristaltic waves from left to right before vomiting occurs, olive sign (mass in mid-epigastrum) - Dx: palpate olive sign, ultrasound, upper GI X-rays, CBC w/ BMP - interventions: NPO, IV hydration, prep for surgery
rheumatic heart disease (RHD): definition, cause, s/s, interventions/nursing considerations
- definition: systemic inflammatory disease where repeated infection causes immune system to inflame and scar the heart valves - cause: untreated group A strep infection (strep throat, rheumatic fever, scarlet fever) - s/s: abdominal pain, epistaxis, chest pain, heart palpitations, paroxysmal nocturnal dyspnea, nonpruritic rash, fever, heart block, subcutaneous nodules - interventions: in children with rheumatic fever cardiac function should be monitored, administer anti-inflammatory meds (corticosteroids or NSAIDS) and antibiotics, educate family on how to prevent recurrence and possibility of surgical valve repair
Tricuspid atresia: definition, clinical manifestations, diagnosis
- definition: tricuspid valve is either defective or missing entirely which block blood from flowing from the right atrium into the right ventricle; blood is only capable of circulating through accompanying defects including VSD, ASD, and PDA - s/s: cyanosis, SOB, slow growth/weight gain, murmur (due to ASD), pulmonary stenosis, clubbing - Dx: echocardiogram, chest x-ray, cardiac catheterization
Henoch-Schonlein Purpura (HSP): definition, s/s, Dx, Tx
- definition: vasculitic disorder triggered by URI that causes autoimmune IgA accumulation in capillary beds - s/s: tetrad= purpuric rash (palpable), arthralgia, abdominal pain, hematuria; also have proteinuria, malaise, facial/hand/feet edema - Dx: anemia from hemolysis, thrombocytosis, leukocytosis, urinalysis with proteinuria and hematuria, skin and renal biopsy showing IgA deposition - Tx: steroids, HTN meds, monitor i/o and daily weights, dialysis is severe ***can cause intussesception
Failure to thrive: definition, assessment questions, Tx
- definition: weight gain for age that is less than the 5th percentile on multiple occasions OR weight deceleration that crosses two major percentile lines on a growth chart - questions: feeding assessment, quantity of food, ability to suck/chew/swallow, food refusal/fixation, feeding practices, gagging, breastfeeding/bottle feeding assessment, 24 hr diet recall for infants, 3 day diet recall for older children - Tx: hospitalize to safely increase nutrition without causing refeeding syndrome, nutritionist referral, parental education, determine and treat underlying cause
PDA: definition, assessment findings, 3 meds to induce closure?
- definition: when the normal hole between the pulmonary artery and the aorta found during fetal development fails to close and increases pulmonary blood flow - assessment findings: systolic murmur that sounds like a washing machine, crackles in lungs, tachypnea, increased WOB, apnea, poor feeding/diaphoresis with feeding (cant breathe well while the eat), poor weight gain and slow growth due to poor feeding, fatigue, excessive fluid weight gain (pulmonary edema) - meds: ibuprofen, indomethacin, acetaminophen/paracetamol
Omphalocele vs Gastroschisis
- omphalocele: intestines are contained in a sac of amino, peritoneum, and Wharton's jelly - gastroschisis: intestines outside the body and not covered with protective layer, increased risk for vascular compromise - interventions for both include planned c/s, orogastric tube, non-adherent gauze in sterile saline to cover defect, IV antibiotics, surgical closure, long term NPO and TPN
Chronic kidney disease: stages, s/s, labs, Tx
- stages: 1= GFR>90%; 2= GFR 60-89%; 3= GFR 40-59%; 4= GFR 15-29%; 5/end= GFR <15% - s/s: HTN, poor growth, abd pain, arthralgias, fatigue, anemia, electrolyte abnormalities, muscle cramps, bone pain, seizures, nausea/vomiting, pruritus, dyspnea - labs: high BUN, high creatinine, high K+, low Na+, metabolic acidosis, anemia, proteinuria, hematuria, possible dysrhythmias - Tx: dialysis, i/o + daily weights, watch for seizures, correct electrolytes; kidney transplant list for end stage
Eisenmenger syndrome
-Uncorrected left-to-right shunt (VSD, ASD, PDA)pulmonary blood flowpathologic remodeling of vasculaturepulmonary arterial hypertension. RVH occurs to compensateshunt becomes right to left. -Causes late cyanosis, clubbing (see picture), and polycythemia. -Age of onset varies
What congenital heart defects fall into the obstructive disorder category?
Coarctation of the aorta Aortic stenosis Pulmonary stenosis Pulmonary atresia Tetralogy of fallot only with pulmonary atresia obstruct blood flow inside of or out of the heart
What are some components of a general history that can detect cardiovascular disorders?
Gestational age at birth: low gestational age increases risk for PDA Feeding history/weight gain: poor feedinging/cyanosis with feeds? Developmental milestone status: not meeting milestones can indicate poor oxygenation Respiratory status: many cardiac disorders have respiratory complications/symptoms Pain: not a common finding, but can indicate MI due to Kawasaki disease
What are assessment findings that are associated with cardiomyopathy?
Hepatomegaly with venous congestion Feeding diaphoresis and fatigue Dizziness frequent respiratory infections Dysrhythmias
What cardiac disorders are considered mixed disorders?
Hypoplastic left heart syndrome Rheumatic heart disease Kawasaki's disease Great vessel disposition Truncus arteriosis result when blood from pulmonary and systemic circulations mix in the heart chambers which results in low SpO2 and decreased cardiac output
What are risk factors for developing a congenital heart defect?
Maternal: infection, alcohol/substance use during pregnancy, DM Genetic: fam Hx of CHD, trisomy 21, presence of other congenital anomalies or chromosomal abnormalities
What are some possible indications of congenital heart disease in children?
Poor weight gain/Failure to thrive Small for gestational age Developmental disabilities Chest wall deformities Scoliosis Clubbing and erythema in fingers and toes due to chronic hypoxia Polycythemia (thickening of blood due to increased RBC mass)
Where are the heart sounds heard and what is "normal"?
S1: lub sound is made by the closure of the mitral and tricuspid valves and heard at the apex of the heart S2: dub sound is made by the closure of the pulmonic and aortic valves S3/S4: gallop that is considered normal before the age of 20
What disorders are considered decreased pulmonary blood flow disorders?
Tetralogy of Fallot Tricuspid atresia Eisenmenger's syndrome ** decreased blood arriving at lungs to be oxygenated resulting in low SpO2 and cyanosis
What are the components of the physical exam portion of the cardiac assessment?
Vitals: pulse ox, Inspection: color, chest shape, finger clubbing, chest movement when breathing, cap refill Palpation: skin and body temp, moisture/sweat, PMI, chest movement, pulses, edema, Percussion: tap to hear dullness which would indicate fluid or mass Auscultation: listening with stethoscope for S1, S2, murmur, clicks, rubs, snaps
What is an echocardiogram?
an ultrasound of the heart; noninvasive method for monitoring cardiac performance, can be done externally or transesophageal
