Pediatrics Exam 4
What are the clinical manifestations of a TEF or EA?
-newborn with frothy saliva in mouth and nose -choking and coughing -cyanosis and apnea -stomach distention -aspiration
What are some home care instructions of an infant with SBS?
-nonnutritive sucking -oral stimulation -small amounts of oral feeding as prescribed
Which TEF-EA is classified as TYPE A: 1. a blind pouch with no communication to the trachea 2. upper segment of esophagus opens directly into trachea (risk of aspiration) 3. proximal esophageal segment ends in a blind pouch and distal end is connected to trachea 4. trachea and esophagus are connected by a fistula
1. 1. a blind pouch with no communication to the trachea
What are three ways to medically manage CDH?
1. ECMO - extra-corporeal membrane 2. high frequency ventilation 3. surgical repair of diaphragm
Progression of MRSA can cause what two things?
1. cellulitis 2. sepsis
What are two ways to diagnose intussusception?
1. rectal exam showing mucus and blood 2. barium enema
What are three long term complications of a cleft palate?
1. speech problems 2. URI's 3. hearing loss
What is normal urine output for an older child/adult
30 cc/hr
What is a normal pH in a urine analysis?
4.8-7.8
What is done in a rectal biopsy?
A small portion of large intestine is removed and examined for absence of ganglion cells
What else could easily occur in an infant with cleft lip/cleft palate?
Chronic ear infections
***Cobblestoning of mucosa: Crohn's or ulcerative colitis?
Crohn's
Segmental, asymmetric distribution of lesions (skip areas): Crohn's or ulcerative colitis?
Crohn's
HSV limited to children between 6 months and 3 years
HSV 6/7
Clinical manifestations include a very large, hard inflamed lump
MRS
What is the medical management of hypertrophic pyloric stenosis?
Surgery - pyloromyotomy
What is the treatment for hirschsprung disease?
Surgical removal of the aganglionic part of the bowel to restore normal motility
How do prokinetics reduce GERD?
They increase LES pressure and the rate of gastric emptying Ex. reglan
What is a pyloromyotomy?
They make a longitudinal incision through circular muscle of the pylorus into the submucosa which releases restriction and establishes adequate passageway
***Intestinal bleeding is common: Crohn's or ulcerative colitis?
Ulcerative colitis
Which part of the GI system does ulcerative colitis affect?
Ulcerative colitis involves inflammation of the mucosa and submucosa of the colon and rectum
What is the gold standard when it comes to diagnosing VUR?
VCUG - voiding cystourethrogram
How is chickenpox spread?
airborne
HSV 3 is aka
chickenpox
Tinea means
fungal infection
What is a repogle catheter?
used to remove secretions in an EA before surgery
Elevated skin lesion containing fluid
vesicle
Warm, red, raised lesion (hives, urticaria, allergic reaction)
wheal
What time of year does AGN commonly occur?
winter
What is the pathophysiology of Hirschsprung disease?
-absence of ganglion cells in parts of the colon causes lack of nerve stimulation, decreased ability of the internal sphincter to relax (decreased peristalsis), and accumulation of intestinal contents (megacolon)
What are some long term complications of gastroschisis?
-bowel adhesions -bowel obstruction -severe GERD
What are some clinical manifestations of AGN?
-edema (weight gain) -dark-colored urine (hematuria) -oliguria -proteinuria -hypertension
What are some clinical manifestations of a UTI in a young child?
-enuresis (especially at night) -abdominal pain -vomiting -fever -strong-smelling urine -dysuria -frequency -urgency
What are the clinical manifestations of Hirschsprung disease in a newborn?
-failure to pass meconium within 24-48 hours after birth -refusing food, vomiting, abdominal distention
Which foods decrease LES pressure and should be avoided to prevent GERD?
-fatty foods -chocolate -tomato products -carbonated beverages
What are some clinical manifestations of a UTI in an infant?
-fever -FTT -vomiting/diarrhea -abdominal distention -jaundice -strong odor to urine
Which foods increase gastric acid secretion and should be avoided to prevent GERD?
-fruit juices -citrus products -spicy foods
What results would you get from a urine analysis done on a patient with AGN?
-hematuria wi/ RBC casts -proteinuria -increased specific gravity
What is a typical diet for a patient with Crohn's or ulcerative colitis?
-high protein -high calorie -iron and folic acid supplements
What is the therapeutic management of cryptorchidism?
-hormone therapy -orchiopexy
What are the major concerns with a gastroschisis?
-infection -heat and fluid loss from exposed viscera
What is a grade five VUR?
-into renal pelvis -major dilation
What is a grade three VUR?
-into renal pelvis -mild dilation
What is a grade four VUR?
-into renal pelvis -moderate dilation
What is a grade two VUR?
-into renal pelvis -no dilation
What is a grade one VUR?
-into ureters only -no dilation
What are some things you could do to help your infant with feeding?
-keep them upright -smaller, more frequent amounts (increase calories per ounce) -use longer nipples
What are four major signs of nephrotic syndrome?
-massive proteinuria -hypoalbuminemia -hyperlipidemia -edmea
What position should you place a patient that has just had cleft lip surgery?
-supine or side lying
What makes up the upper urinary tract?
-ureters -renal pelvis -calyces -renal parenchyma
What makes up the lower urinary tract?
-urethra -bladder
What are three pharmacologic treatments of GERD?
1. antacids/histamine receptor antagonists (zantac, pepcid) 2. proton pump inhibitor (prilosec) 3. prokinetic (reglan)
Diarrhea is the main symptom of short bowel syndrome (SBS) and as a result the two big things we need to watch for are:
1. dehydration 2. malnutrition
***How can we prevent necrotizing enterocolitis?
1. hold oral feedings for 24-48 hours if history of birth asphyxia 2. give breast milk rather than formula
What two things are used with a patient who has just had cleft lip surgery?
1. logan bow (two wires that pull the cheeks together) 2. elbow/arm immobilizers
What are the three types of nephrotic syndrome?
1. minimal-change nephrotic syndrome (MCNS) 2. secondary 3. congenital
What two things should you look for as a nurse caring for a patient with possible imperforate anus?
1. passage of meconium 2. presence of stool in urine or vagina
What are three clinical manifestations of VUR?
1. persistent/recurrent UTI 2. renal disease 3. poor growth
What are four major clinical manifestations of hypertrophic pyloric stenosis?
1. projectile vomiting - contains milk/formula but NO bile 2. visible gastric peristalsis 3. olive-shaped mass in epigastrium just to the right of the umbilicus 4. FTT
What two diagnostic tests are used to test for Hirschsprung disease?
1. rectal biopsy 2. barium enema
What two things would be seen on x-ray of a patient with necrotizing enterocolitis?
1. sausage-shaped dilation of intestine and bubbly appearance of thickened bowel wall (pneumatosis intestinalis) 2. pneumoperitoneum
What are four nonpharmacologic treatments for GERD?
1. small frequent feedings and frequent burping 2. avoid foods that make acid reflux worse 3. thickening of feeds 4. positioning of the infant
***What are five clinical manifestations of intussusception?
1. sudden episode of acute, colicky abdominal pain (screaming and drawing up knees to chest) 2. intervals where the child is comfortable 3. vomiting 4. sausage-shaped mass in RUQ 5. Jelly-like stool (stool mixed with blood and mucus)
What is a normal specific gravity in a urine analysis?
1.016-1.022
When is surgical repair usually done for a cleft palate?
12-15 months
What age does ulcerative colitis peak at?
15-20 years
Which of the following urine analysis results is abnormal? 1. specific gravity = 1.019 2. pH = 5.4 3. protein, glucose, and ketones present 4. RBC count <1
3. protein, glucose, and ketones present
The nurse should carefully observe the infant with a tentative diagnosis of pyloric stenosis for: 1. Quality of cry 2. Quality of stool 3. Signs of dehydration 4. Coughing and gagging after feeding
3. signs of dehydration
A nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician? 1. Bloody diarrhea 2. Hypotension 3. A hemoglobin level of 12 mg/dL 4. Rebound tenderness
4 - rebound tenderness indicates peritonitis which is serious and needs to be reported
At what week gestation are the esophagus and stomach identified?
4 weeks gestation
Which TEF-EA is classified as TYPE E: 1. a blind pouch with no communication to the trachea 2. upper segment of esophagus opens directly into trachea (risk of aspiration) 3. proximal esophageal segment ends in a blind pouch and distal end is connected to trachea 4. trachea and esophagus are connected by a fistula
4. trachea and esophagus are connected by a fistula (risk of aspiration)
The nurse is providing education to a family whose child was just diagnosed with Gastroesophageal Reflux. Which of the following do the caregivers need to know regarding safety at home? a) Keep the child in an upright position for an hour after feeding b) Lying flat on the right side will alleviate symptoms c) Avoidance of certain foods d) Diet changes are never necessary if the child is on medication
A and C
What is done in a barium enema?
A small tube is placed in rectum and barium contrast is pushed into the large intestine (this tells us the transition zone)
What is the haberman feeder?
A specially designed bottle and nipple with a one way valve that adjusts the flow of formula for babies with sucking problems
How is peristalsis difference in a pediatric patient vs. an adult patient?
Children have faster peristalsis and infants can have reverse peristalsis (causing regurgitation)
Frequent recurrences:; Crohn's or ulcerative colitis?
Crohn's
Which part of the GI system does Crohn's affect?
Crohn's involves the entire GI tract and all layers of the bowel wall
Which disease tends to have more serious complications and the medical/surgical treatment is less effective: Crohn's or ulcerative colitis?
Crohn's tends to have more serious complications and the medical/surgical treatment is less effective
T/F a Celiac's patient is allowed to have commercially prepared ice cream and pudding in their diet
FALSE
T/F breastfeeding is possible with a cleft palate
FALSE
Clinical manifestations occur in 3 stages: Stage one: SLAPPED FACE appearance (erythema on face/cheeks) Stage two: maculopapular red spot on UE and LE one day after rash appears Stage three: rash subsides but comes back whenever skin is irritated
Fifth disease (erythema infectiosum)
You are a nurse preparing to do a barium enema in a patient suspected of having intussusception. What is it important to do before giving the enema?
Get an abdominal x-ray to check for any intraperitoneal air indicating a bowel perforation
Clinical manifestations include a high fever for 3-4 days that goes away and is replace by rash with rose-pink macules starting on trunk, then on trunk, then on face
HSV 6/7
Clinical manifestations include fever, fatigue, pharyngitis, SPLEEN ENLARGEMET
HSV type 4
***The most common clinical manifestation of this disease in a child is chronic constipation with ribbon-like, foul smelling stools and abdominal distention
Hirschsprung disease
This disease is a congenital anomaly resulting in mechanical obstruction from inadequate motility of part of the intestine
Hirschsprung disease (ACUTE or CHRONIC)
How does necrotizing enterocolitis develop?
Ischemia causes damaged/dead cells. Mucosal enzymes can now further break down the intestinal wall. Bacteria invade the damaged area and peristalsis stops causing abdominal distention
Type of staph that is resistant to certain antibiotics
MRSA
What is the diagnostic tool used to diagnose CDH?
Meckel scan
Why would we need to reassure parents to place GERD infants in prone position when sleeping?
Most are aware of the recommondation to position infants in the supine position to prevent SIDS so we will have to reassure them of the importance of placing their baby in the prone position in order to prevent GERD
This is an acute inflammatory disease of the bowel in preterm/high-risk infants
Necrotizing enterocolitis (NEC)
Raised, skin color lesion
Papule
T/F CDH can be diagnosed and treated in utero
TRUE
T/F HSV symptoms are often precipitated by overexposure to sunlight, febrile illness, stress
TRUE
T/F Hirschsprung disease is usually associated with other anomalies like Down's
TRUE
T/F MRSA lives on the skin and is easily transmitted
TRUE
T/F part of nursing management for VUR could include screening for sibling
TRUE
T/F the stomach lies horizontally until age 2
TRUE
T/F there is a relationship between formula feeding and the development of necrotizing enterocolitis
TRUE
T/F a patient with HSV 4 should not play contact sports
TRUE - risk for enlarged spleen
Why would edema be a clinical manifestation of AGN?
The blockage of the kidneys causes the edema
A 6-month old, previously healthy child comes in and won't stop screaming and keeps pulling his knees up to his chest. What clinical manifestations would indicate to the nurse that the child has intussusception?
There is a sausage-shaped mass in the right upper quadrant and the child is vomiting and has jelly-like stool
What will a patient with Celiac's disease supplement for gluten in order to maintain a gluten-free diet?
They can substitute corn, rice, and millet as grain sources
Which age group does Crohn's tend to affect?
Younger populations
A postinfectious kidney disease
acute glomerulonephritis (AGN)
How can you thicken an infant's feed?
add 1tsp - 1tbsp of rice cereal per ounce of formula
What is pneumoperitoneum?
air in the abdomen (indicting the bowel has perforated or torn and air has leaked out)
What lab would help us determine level of malnutrition in a patient with GI dysfunction?
albumin and prealbumin
What is a fistula?
an abnormal connection between things
What is an atrasia?
an abnormal opening
What would a lab done on a child with Crohn's or ulcerative colitis show us?
anemia and inflammation from increased erythrocyte sedimentation rate
What is used for pain management with hypospadias/epispadia?
anticholinergics (like dotripan) to relieve bladder spasms
How should the nurse respond to a fever day 5 after a GI surgery?
be concerned because there shouldn't be a fever
The AAP guidelines for evaluating febrile infants and children from 2 to 24 months recommends obtaining a urine specimen for culture and urinalysis before what?
before an antimicrobial agent is administered
Why wouldn't a nurse report bloody diarrhea and hypotension in a patient with ulcerative colitis?
bloody diarrhea and hypotension are expected findings
Your patient has a fever, abdominal distention, vomiting, abdominal tenderness, dyspnea, and cyanosis. What should be your primary concern?
bowel perforation
In children under 2 y.o. with a possible UTI, what is the preferred method of collecting a urine specimen?
catheterization or suprapubic aspiration
What effect can congenital diaphragmatic hernia have on the lungs?
causes compression of lungs by abdominal organs (they develop pulmonary hypoplasia)
Clinical manifestations include swollen, red, warm skin occasionally with streaking
cellulitis
Localized infection secondary to break in skin barrier, usually staph, strep, of H flu, penetrate dermis and sub Q tissue
cellulitis
Clinical manifestaions include "dew drop on a rose petal" rash, fever, fatigue, decreased appetite
chickenpox HSV 3
Downward curvature of the penis is known as
chordee
This facial deformity includes the external nose, nasal septum and dental anomalies
cleft lip
This occurs from incomplete fusion of the embryonic structures surrounding the primitive oral cavity
cleft lip
This facial deformity includes the nostril/complete absence of the nasal septum
cleft palate
This occurs when the primary and secondary palatine plates fail to fuse during embryonic development
cleft palate (CP)
Failure of diaphragm to form completely in utero is known as:
congenital diaphragmatic hernia (CDH)
A disorder characterized by undescended testis
cryptorchidism -also retractile testis (cremasteric reflex)
What is the first thing done with an infant born with untreated CDH?
emergency endotracheal intubation
If there is a failure of the esophagus to develop as a continuous passage it is called:
esophageal atresia (EA)
How often should BP measurements be taken in a patient on diuretics for AGN?
every 4-6 hours
Why would an infant with GI dysfunction be hypokalemic?
excessive vomiting could cause decreased potassium levels
What is the final phase of feeding with an SBS patient?
exclusive enteral feedings
When is surgical repair usually done for a cleft lip?
first few months of life
If an infant has a cleft lip and cleft palate, which would be repaired first?
first the cleft lip repair then the cleft palate repair
This occurs when the bowel herniates through a defect in the abdominal wall to the right of the umbilical cord and through the rectus muscle
gastroschisis
HSV 2 is known as
genital herpes
Clinical manifestations include low grade fever, headache, malaise, sore throat, cough, rash starting on face and spreading downward that disappears on the third day
german measles (rubella)
AGN is an infection by which organism?
group A hemolytic streptococcus
***This condition causes PROJECTILE VOMITING which leads to dehydration, METABOLIC ALKALOSIS and FTT
hypertrophic pyloric stenosis (HPS)
When should the parents of a discharged patient with SBS be concerned?
if their child starts to develop a fever (indicating infection)
Absence of a normal anal opening is known as
imperforate anus
Infection when staphylococcus aureus and streptococcus invade the dermis
impetigo
What is the first sign that a patient with AGN is recovering?
increased urine output and decreased body weight
What is the second phase of feeding with an SBS patient?
introduction of enteral feeding
What does a UGI (upper GI x-ray) tell us?
it tells us about the mucosal intactness
small, irregular red spots with bluish white center on buccal mucosa
koplik spots (seen with measles)
What are normal creatinine levels in an infant?
less than 0.4 mg/dL
What are normal creatinine levels in a child?
less than 00.7 mg/dL
What are normal creatinine levels in an adolescent?
less than 1 mg/dL
What are normal BUN levels in a newborn?
less than 12 mg/dL
What are normal BUN levels in an older patient?
less than 18 mg/dL
Cystitis/urethritis is UTI in which part of the urinary tract?
lower urinary tract
Small, flat skin lesion less than 1cm
macule
Raised skin lesion with a color change
maculopapule
Which type of nephrotic syndrome is most common in preschool children?
minimal-change nephrotic syndrome
How is strep throat treated?
oral antibiotics: penicillin
Management of lice includes treatment using
pediculocide (be aware it is neurotoxic)
What is the most significant sign of necrotizing enterocolitis?
pneumatosis intestinalis (gas in the intestinal wall)
What is the most common sign of pyloric stenosis?
projectile vomiting
How should you care for a gastroschisis pre-op?
protect the viscera with moist dressings or silo
Elevated skin lesion containing fuid (pus, bacteria related)
pustule
HSV 3 is AKA
shingles
Clinical manifestations include vesicular eruption along affected nerve/dermatome, stinging, burning, and tingling clustered group of vesicles
shingles HSV 3
Clinical manifestations include sore throat, fever, sandpaper-like rash
strep throat
Why would the antistreptolysin (ASO) titer be increased in a patient with AGN?
the presence of the streptococcus
What is a persistent cloaca?
the rectum, vagina, and urethra all drain into a common channel opening into the perineum
Which trimester is the period of the most extensive and rapid growth?
the third trimester
How are a newborn's glomeruli different from an adult's?
they are enlarged after birth
Clinical manifestations include an annular lesion that is flaky in center and also there is hair breakdown (more common in dark people)
tinea capitis (superficial, on scalp)
Clinical manifestations include an annular, well-defined red border with central clearing (superficial: upper epidermis)
tinea corporis
Why would a patient have an NG tube following GI surgery?
to help pull out excessive secretions from the GI tract (not for nutrition)
Why should oral stimulation be encouraged in an infant following a GI surgery?
to preserve the suck/swallow reflex
If there is a failure of the trachea and esophagus to separate into distinct structures it is called:
tracheoesophageal fistula (TEF)
How should the nurse respond to a fever the day after GI surgery?
treat appropriately but it is anticipated
Continuous, symmetric distribution of lesions: Crohn's or ulcerative colitis?
ulcerative colitis
Cured with a colectomy: Crohn's or ulcerative colitis?
ulcerative colitis
Superficial, extensive ulceration: Crohn's or ulcerative colitis?
ulcerative colitis
pyelonephritis is a UTI in which part of the urinary tract?
upper urinary tract
A child with GERD was prescribed Prilosec, a proton pump inhibitor that decreases GERD by reducing gastric acid secretion. What should the nurse be aware of as possible side effects to Prilosec?
-nausea/vomiting -diarrhea/constipation -abdominal pain -headache/dizziness
What is normal infant urine output?
1 cc/kg/hr
What is normal neonate urine output?
1-2 cc/kg/hr
What is an important nursing intervention for a pre-op patient with hirschsprung disease?
1. Measure the abdominal curve
What are two therapeutic managements of VUR?
1. continuous antibiotic prophylaxis (CAP) 2. surgery
What are the two most serious complications with intussusception?
1. perforation 2. peritonitis
What two diagnostic tests are used to test for hypertrophic pyloric stenosis?
1. x-ray - will show a dilated stomach 2. ultrasound - will show the pyloric mass
Which TEF-EA is classified as TYPE B+D: 1. a blind pouch with no communication to the trachea 2. upper segment of esophagus opens directly into trachea (risk of aspiration) 3. proximal esophageal segment ends in a blind pouch and distal end is connected to trachea 4. trachea and esophagus are connected by a fistula
2. upper segment of esophagus opens directly into trachea (risk of aspiration)
An infant is diagnosed as having pyloric stenosis. When palpating this infant's abdomen, the nurse would expect to find: 1. An impacted and distended colon 2. Marked tenderness around the umbilicus 3. An olive-sized mass in the right upper quadrant 4. Rhythmic peristaltic waves in the lower abdomen
3. an olive-sized mass in the right upper quadrant
Which TEF-EA is classified as TYPE C: 1. a blind pouch with no communication to the trachea 2. upper segment of esophagus opens directly into trachea (risk of aspiration) 3. proximal esophageal segment ends in a blind pouch and distal end is connected to trachea 4. trachea and esophagus are connected by a fistula
3. proximal esophageal segment ends in a blind pouch and distal end is connected to trachea -stomach distends with air -gastric contents regurgitate through fistula into trachea
What can parents use to help their GERD infant sleep in the prone position?
Commercially made harnesses or an improvised harness made with a baby blanket
***Most frequently affected site is the terminal ileum: Crohn's or ulcerative colitis?
Crohn's
Deep ulcerations: Crohn's or ulcerative colitis?
Crohn's
Strep throat
Group A beta-hemolytic streptococci
This disease is the inversion of one part of the intestine within another
Intussusception (occurs in healthy children 3-12 months)
What is initial phase of feeding with an SBS patient?
TPN
T/F breastfeeding is possible with a cleft lip
TRUE
T/F parents should avoid vigorous play following feedings and avoid feeding just before bedtime with children with GERD
TRUE
What positions can decrease GERD in an infant?
The upright or prone position can decrease GERD
What is important to remember about proton pump inhibitors?
They have increased side effects like nausea, vomiting, diarrhea, and constipation Ex. prilosec
What is the median age of onset for AGN?
between 6 and 8 years
What is teatorrhea?
impaired fat absorption
How is a newborn's loop of Henle different from an adult's?
newborns have a short loop of Henle
When will gastroschisis be surgically repaired?
within 24 hours of birth