PEDS EXAM 2

therapeutic management / smoke inhalation injury

- humidified 100 oxygen asap nonrebreather or hyperbaric - monitoring for signs of respiratory distresss - baseline blood gases and COHb labs checked respiratory distress may occur later so prepare endotracheal entubation equipment assessment and localization of obstruction ( due to edema?)

kidneys in children

- more mobile than in adults - outer border less well protected - separated from skin surface 2-3 cm - increased risk of renal trauma

severity of hypospadias

- position of the urethral opening - degree of chordee ( ventral curvature of the penis) the more distant and the more curvature - more severe and needs surgery

Water balance

- under normal conditions the amount of water and ingested closely approximate the amount of urine excreted in a 24-hour period -Water and food and from oxidation closely approximate the amount lost in feces into evaporation Under normal conditions the amount of water ingested closely approximates the amount of urine excreted in a 24-hour period. Water in food and from oxidation closely approximates the amount lost in feces and through evaporation; Must take into account insensible water losses, respirations, skin evaporation, stool. Body is usually able to compensate for these losses. Body fluids are the medium in which the body solutes are dissolved and metabolic reactions take place.

cryptorchidism

failure of one or both testicles to descend into the scrotum through the inguinal canal

treatment of poor perfusion from dehydration

-volume restoration -central venous pressure monitored -physiological and biochemical abnormalities should be corrected - catjeter inserted to rule out urine retention and to collect urine for analysis and to monitor results of diuretics mannitol, furosemide and loop diuretics are not helpful

Daily Maintenance Fluid Requirements

1-10kg - 100 ml/kg 11-20 kg - 1000 ml plus 50 ml/kg for each kg >10 kg >20 kg 1500ml plus 20 ml/kg for each kg>20 kg

syndromes of pulmonary complications from inhalatory injury

1. early carbon monoxide poisoning, airway obstruction, pulmonary edema 2. ARDs 24-48 hr later 3. pneumoni, pulmonari emboli strangulaions from cervical eschar secondary to severe bursn

intubation is needed

1. severe burns in the area of nose. mouth and face will increase likelihood of developing oropharengeal edema and obstruction 2. vocal cord edema cause obstruction 3. patient has difficulty handling secretions 4. progressive respiratory distress requires artificial ventilation

Antidiuretic Hormone

ADH released from anterior pituitary in response to decreased intravascular fluid volume. ADH promotes H2O retention in renal system

insensible water losses

2/3 - through skin 1/3 through respiratory tract influenced by - emvironmental heat, humidity, skin integrity, body temperature, respiratory rate

azotemia

Accumulation of nitrogenous waste in the bloodstream. Occurs when the kidney fails to filter these wastes from the blood. not life thretening

nursing care in children after smoke inhalation

keep airway patent effective ventilation status endotracheal intubation monitor vital signs, oxygenation, work of breathing, other respiratory assessment administration of nebulizer bronchodialators humidified oxygen, inhaled corticosteroids fluid requirements, but due to the risk of pulmonary edema watch I/O

hypospadias

Congenital anomaly in which the opening of the urethra is on the underside of the penis

nursing care of AKI

underlying cause treatment monitor renal status reestablishing renal function prevention of complicaation monitoring fluid balance, physical manifestations major - monitoring and assessing fluid and electrolyte balance meeting nutritional needs monitor IV to prevent fluid overload optimal thermal environment reduce anxiety watch for complications

clinical manifistations of acute kidney injury

underlying illness overshadows the renal failure prime manifestations: - oliguria ( less than 1 ml/kg/hr) - anuria ( no output in 24 hrs) - edema -drowziness - circulatory congestion causing CNS manifestations - cardiac arythmias from hyperkalemia

absence of testes within scrotum

undescended testes retractile testes absent testes ascended testes

heat injury

upper airways reflex closure of the glottis prevents injury to lower airways doesnt penetrate the lungs`

communicating hydrocele

when the process vaginalis doesnt close during dvelopment, allowing communication with the peritoneum may change during the day with starining surgery after 1 year ( bath in 3 days)

Maintenance fluids

Fluid requirement for basic metabolic functions water + electrolytes estimated from the child's age, body weight, degree of activity, body temperature ex febrile patient at rest 1- ml fro each 100 kcal expended

Water Balance in Infants

Greater fluid intake and output relative to size. Disturbances occur more frequently and rapidly.

Mechanisms of Fluid Movement

Hydrostatic pressure, Osmotic pressure, Diffusion, Active transport, Vesicular transport

acute kidney injury

kidneya suddenly are unable to appropriately regulate the volume and composition of urine in response to food and fluid intake and the needs of the organism symptom oligoanuria

Total Body Water

Relatively constant amount, H2O major constituent of body tissues, 75% in infants decreases to 45% by late adolescnse

Distribution of Body Fluids

Total body water (TBW), Involved ICF, Involves ECF (intravascular, interstitial, transcelluar)

hydrocele

precence of peritoneal fluid in the scrotum between the parietal and visceral layers of the tunica vaginalis most common cause of painless scrotal swellingasnd nonincarcerated inguinal hernia common in newborns, resolve by 12 m

surgical corrections of hypospadias

primary tubularization ( new urethra is made) onlay island flap is used to create the urethra, transferring the strip of inner foreskin onto the ventral urethral plate straightening the penis + creating a new urethra chordee is repaired by release of ventral skin

anorchidism

absence of testes due to genotypic and phenotypic abnormalities or congenital adrenal hyprplasia

renal rapture

actual splitting open of the kidney capsule, causing extravasation of blood or a mixture of blood and urine into the surrounding retroperineal space immediate surgical intervention due to possible rapid blood loss

potassium can be removed

administration of cation exchange resin like sodium polysterene sulfonate dyalisis or continuous hemofiltration

small object partially obstructs a passage

air passes around the obstruction during both inspiration and expiration wheezes are heard

complete blockage

air unable to move in either direction and the air distal to the obstruction is absorbed, leaving an area of obstruction atelectasis

larger obstruction

air will enter distal portion when bronchioles enlarge during inspiration during expiration they diminish, lumen occludedand air is trapped distal to the obstruction produces obstructive hyperventilation

fluid and calories in acute renal injury

amount of exogenous water shouldn't exceed the amount needed to maintain zero water baance child with AKI tends to develop water intoxication, hyponatremia -> causing difficulty to provide enough calories

other complications of AKI

anemia seizures coma cardiac failure pulmonary edema transfusion if Hg below 6 g ( packed red blood cells slowly) to treat anemia treatment of seizure - treat the cause like hypertension, hyponatremia, hypocalcemia cardiac failure and pulmonary edema are due to hypervolemia, so reduce fluid volume - restrict sodium and water and administration of diuretics

Oligoanuria

associated with azotemia, acidosis and diverse electrolyte disturbances

Ectopic testis

testis positioned outside of scrotum due to obstruction of the scrotal inlet, scarring of gubernaculum, mechanic anomalies

pulmonary care after smoke inhalation injury

bronchodialitors inhaled corticosteroids humidification CPT bronchoscopy to clear heavy secretions

clinical course acute kidney injury

the evolution of the disease: - severe oliguria (10-14 days) - low-output phase - abrupt onset of diuresis - high output pahase - gradual return to normal urine volume

uremia

the retention of toxic body waste in blood

serum potassium reduction measures transient protection

calcium gluconate IV over 30-60 min ( risk of hypocalcemia, tetany, fluid overload) glucose and insulin administered IV to accelerate glycogen synthesis to move glucose and potassium into the cells do not remove from the body potassium, just rearranging

recurrent pneumoni

check for FB in airways

nursing care after hypospadias

circumsions should be avoided may require urinary diversion with a stent to promote healing ( 5-10 days) with a bladder bag or into the diaper pain control anticholinergic to prevent spasms due to catheter antibiotic might be needed after catheter anticholinergic cause constipation -> give fluids, stoool softeners or laxatives bath in 3 days put petroleum jelly ro prevent sticking to the diaper avoid straddling toys, swimming, sandbox, until allowed by MD

chemical injury

combustion can generate gases acids, alkalis can produce chemical burns go deep into the respiratory tract synthetic materials especially toxic ( like plastic nitrous oxide or carbon dioxide bombine with water in lung and become corrosive aldehydes cause denaturation of proteins, cellular damage and edema od pulmonary tissues chemocal burns are painless in airways

hypertension

complication of AKI goal is to prevent hypertensive excephalopathy and avoid overtaxing the cardiac system - give labetalol ( beta and alpha blocker) IV as bolus or sodium nitroprusside ( monitoring closely) urgent situations IV- hydralizine, clonidine, verapamil oral - nifedipine, captopril, minoxidil, hydralizine, propranolol, furosemide

if child with AKI can tolerate oral food

concentrated high carbs and fat low protein, potassium and sodium IV if nausea and vomiting - amino acids central vein

necrotic processes within nephron can be

cortical necrosis tubular necrosis clinical course

bronchial obstruction produces

cough wheezing assymetric breath sounds decreased airway entry dyspnea

retractile testes are due

cremasteric reflex can be gently moved into the scrotum

internal control mechanisms influencing fluid balance

thirst antidiuretic hormone aldosterone renin-angiotensin system

hyperkalemia

threat to life of child with AKI can cause cardiac arythmias and cardiac arrest, so monitor ECG and serum potassium eleminate potassium from food

therapeutic measure for FN

thrusts rarely coughed out spontaneously so should be removed by endoscopy or bronchoscopy asap to prevent inflammation ( which will make it difficult) or chemical pneumona

tubular necrosis

damade tothe renal tubules associated with ingestion or inhalation of substances toxic to the kidneys reepithiliazation causes lesions, preventing establishment of tubular integrity

acute kidney injury /intrinsic renal causes

diseases nephrotoxic agents type and etent determine the degree and duration of renal insufficiency

absent testes

due to agenesis or atrophy from loss of blood suppply secondary to prenatal testicular torsion

laryngotracheal obstruction causes

dyspnea cough stridor hoarseness cyanosis possible

causes of chryptorchidism

endocrine abnormalities denervation of genitofemoral nerve traction of gubernaculum abnormal development of epididymus preterm birth

goal of surgical correction of hypospadias

enhance the child's ability to void in the standing position with a straight stream improve the physical appearance of the genitalia preserve a sexually adequate organ

increased fluid requirements

fever (12% per rise of 1 C) vomiting diarrhe high output kidney failure diabetus insipidus diabetic ketoacidosis burns shock tachypnea radiant warmer phototerapy postoperative bowel surgery

orchiopexy

fixation of an undescended testis in the scrotum 6-24 m nursing care - prevent infection ( cleaning and observation for wound complications), instructing about home care, pain control

suspected renal trauma in children

flank pain abrasions or contusions of the skin hematuria possible fever dysuria is common severe injury - nausea and abdominal pain possible palpable mass caused by loss of blood

interstitial fluid

fluid in the spaces within the cells most abundant

ECF

fluid outside the cells Intravascular in blood vessels; interstitial surrounding the cells; transcellular in pleural spaces, cynovial, body cavities

systemic injury after smoke inhalation

from gases non toxic to airways ( carbon monoxide, hydrogen cyanide) they result in death inhibiting cellular respiration

pathological conditions of acute kidney injury caused by

glomerulonephritis HUS etc

noncommunicating hydrocele

have no connection to the peritoneum with fluid coming from the mesothilial lining of the tunica vaginalis result of - trauma, epididymitis, orchitis, testicular torsion, torsion of the appendix testis or epididymus, tumor no reducible in size

decreased requirements

heart failure syndrome of inappropriate antidiuretic hormone mechanic venticlation after surgery oliguric renal failure increased intracranial pressure

smoke inhalation injuries

heat injury local chemical systemic

diagnosis of FB

history physical signs radiography may not show bronchoscopy is required to diagnose and remove flouroscopic examination is needed to examine bronchi

diagnostic acute kidney injury

history symptoms related to glomerulonephritis, obstructic uropathy, exposure to nephrotoxic chemicals labs of kidney dysfunction: - hyperkalemia - hyponatremia - matbolic acidosis - hypocalcemia - anemia - azotemia

therapeutic management/ renal trauma

hospitalization possible blood replacement bed rest ( 3 days after cessation of gross bleeding)

thrapeutic management undescended testes

if not descended by 6 m, - surgery withing a year

diagnostic evaluation of undescended testes

important to differentiate from retractile testes, whcih can be pushed back into the scrotum explaratory surgery - diagnosis and treatement

renal failure

inability of kidney to excrete waste material, concentrate urine and conserve electrolytes can be acute and chronic

balanitis

inflammation or infection of the phimotic foreskin, occurs ocassionally and treated as any infection ( steroid cream)

complications of undescended testes

inguinal hernia testicular torsion testicular trauma subfetility testicular cancer

fluid losses

insensible urinary fecal

diagnosis of renal trauma

intravenous pyelography angiographhy retrograde pyelography

during high output phase ofAKI

monitor I/O, potassium, sodium provide adequate replacemnt

water control in child with AKI

monitoring I/O body weight electrolyte measurements no sodium, potassioum, chloride labs: plasma electrolyte, pH, BUN, createnine

acute kideny injury/prerenal causes

most common cause - dehydration secondary to diarrheal disease or persistent vomiting surgical shock and trauma ( burnS) azotermia reversible with expansion of extracellular fluid volume rare cause - renal artery stenosis, altered peripheral vascular resistance

therapeutic management acute kidney injury

most effective - prevention - fluid therapy for children with dehydration, burns, hemorrhage - nephrotoxic drugs used cautiously or avoided in children with renal desease - generrous fluid intake for childen receiving antimetabolite drugs and after radiotherapy treatment aimed at - underlying cause - management of the complications of the renal failure - provision of supportive therapy

phimosis

narrowing or stenosis of the preputial opening of the foreskin that prevents retraction of the foreskin over the glans penis ( normal in young boys and infants, disappears later) external cleansing during routine bathing, do not forsible retract

is shock common in renal trauma

no capsule enclosing kidney prevents expansion of a hematoma

chemical injury can lead to

obstructive bronchiolitis alveolocapillary damage with hemorrhage necrotizing bronchiolitis inhibited secretion of surfactant formation of hyaline membranes ARDS

acute kideny injury/postrenal causea

obstructive uropathy ( uncommon) except first year degree of recovery depends on the duration of renal failure

descending of testes

phase 1 - dominated by mullerian inhibiting substance 8-15 weeks gubernaculum extends from the developing testes, anchoring testes to the developing inguinal canal phase 2 - dominated by testosterone 25-30 weeks - shrinkage of gubernaculum, causing the testes to migrate down the inguinal canal and into scrotal position

most common cause of acute kidney failure in children

transient renal failure resulting from dehydration or other causes of poor perfusion

nursing care/ renal trauma

recognizing and assessing renal trauma supportive care

Renin-Angiotensin System

renin excreted in response to decreased blood flow to kidneys (secondary to dehydration or fluid loss), angiotensin produced (vasoconstrictor / stimulates release of aldosterone which increases systemic vascular resistance, increases pressure of blood flow to vital organs

idyopatic hydrocele

repaired symptomatically

reactive hydroceles

resolve with treatment of the underlying cause

cortical necrosis

results from: severe ischemia infection intravascular coagulation mostly in neonatal as a result of hypoxia and shock

signs and symptoms of CO poisoning

secondary to tissue hypoxia headache visual disturbances irritability nausea severe: - confusion - hallucinations - ataxia - coma - pallor - cyanosis delayed neurologic deficit ( 3-240 days after exposure)

Aldosterone

secreted by adrenal cortex, increases Na reabsorption in renal tubules with caused increased reabsorption of H2O

emergency hyperkalemia

serum potassium 7 mEq/L presence of ECG abnormalities - loss of P wave prolonged RS complex, depressed ST segment, tall andtented T waves, bradycardia, heart block

Indications for dialysis

severe persistent acidosis inbility to reduce serum potassium levels to a safe range with other methods clinical uremic syndrome consisting of nausea and vomiting, drowziness and progressing to coma circulatory overload, hypertension and evidence of cardiac failure

Acute kideny injury causes

severe reduction in GFR elevated BUN decreased tubular reabsorption of sodium increased concentration of sodium in the distal tubules

possible inhalation injury signs

sooty material around the nose or in the sputum singed nasal hair mucosal burns of the nose, lips mouth or throat hoarse voice cough increased inspiratory and expiratory stridor ( severe damage)

signs of respiratory distress

tachypnea tachycardia dimnished or abnormal breath sounds - crackles wheezes