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