Pedia Note1

Pedia Notes Physiologic wt loss – 5 – 10% wt loss few days after birth Small GA < (less) 10 Large GA > (more) 90 Physical Exam and Deviations fr Normal 1. if client is new born, cover areas not being examined 2. if client is infant – the 1st yr of life - get VS – take RR 1st - begin fr least intrusive to the most intrusive area 3. if client is a toddler and preschool, let them handle an instrument like: - play syringe or stet, security blanket – favorite article. Let baby hold it. 4. Explain procedure and respect their modesty - school age and adolescent V/S: Temp: rectal- newborn – to rule out imperforate anus •

take it once only, 1 inch insertion

Imperforate anus 1. 2. 3. 4.

atretic – no anal opening agenetic – no anal opening stenos – has opening membranous – has opening

Earliest sign: 1. no mecomium 2. abd destention 3. foul odor breath 4. vomitous of fecal matter 5. can aspirate – resp problem Mgt:

Surgery with temporary colostomy Cardiac rate: 120 – 160 bpm newborn Apical pulse – left lower nipple Radial pulse – normally absent. If present PDA Femoral pulse – normal present. If absent- COA - coartation of aorta

Congenital Heart Dse Common in girls – PDA, ASD atrial septal Common in boys – TOGA ( transportation of great arteries) TA – tronchus arteriosus TOF – tetralogy of fallot Causes: 1.

familial

2. exposure to rubella – 1st month 3.

failure of strucute to progress

acyanotic L to R cyanotic R – L Acyanotic heart defects L to R 1.

ventricular septal defect - opening between 2 ventricles S&Sx 1. systolic murmurs at lower border of sternum and no other significant sign

2. 3.

cardiac catheterization reveals increased o2 saturation @ R side of heart ECG reveals hypertrophy of R side of heart

Nsg Care: Cardiac catheterization: site – Rt femoral vein 1. 2. 3.

NPO 6 hrs before procedure protect site of catheterization. Avoid flexion of joints proximal to site. assess for complication – infection, thrombus formation – check pedal pulses ( dorsalis pedis)

Mgt.

1. 2.

long term antibiotic – to prevent subacute bacterial endocarditis open heart surgery-

2.) ASD – failure of foramen ovale to close S&SX 1. 2.

systolic murmur @ upper border of sternum result of cardiac catheterization & ECG same with VSD Mgt: open heart surgery

3.) endocardial cushion defects - atrium ventricular (AV) - affects both tricuspid and mitral valve Dx – confirmed by cardiac catheterization Mgt: - open heart surgery Antibiotics to prevent subacute bacterial endocarditis 4.) PDA - failure of ductus arteriosus to close - should close within 24 h -complete close – 1 month S&Sx 1.

continuous machinery like murmurs

2. 3.

prominent radial pulse ECG- hypertrophy Left ventricle

Drug: 1. 2. 3.

endomethazine – prostaglandin inhibitor - facilitate closing of PDA ligation of PDA by 3-4 yo thoracotomy procedure- nakadapa child

5.)Pulmunary Stenosis- narrowing of valve of pulmo artery S &Sx: 1.) typical systolic ejection murmur 2. S2 sound widely split 3. ECG- Lt ventricular hypertrophy 6.)Aortic Stenosis – narrowing of valve of aorta S & Sx: 1. inactive, sx sme with angina

2. typical murmur 3. rough systolic sound and thrill 4. ECG- Left ventricular hypertrophy cardiac catheterizationMgt Pulmo Stenosis & Aortic Stenosis 1. 2.

balloon stenostomy surgery

Duplication of Aortic Arch- doubling of arch of aorta causing compression to trachea and esophagus S&Sx : 1. dysphagia 2. dyspnea 3. left ventricular hypertrophy Mgt: - close heart surgery 8.) Coartation of Aorta – narrowing of arch of aorta outstanding Sx : absent femoral pulse BP increased on upper extremities and decreased on lower extremities ECG – hypertrophy Lft ventricle Mgt: close heart surgery CYANOTIC HEART DEFECTS R to L 1. Transportation of Great Arteries (TOGA) - aorta arising from Rt ventricle p u l m o a r t e r y a r i s

i n g f o r m L t v e n t r i c l e

Outstanding Sx:

1. cyanosis after 1st cry (due no exygenation) 2.

polycythemia – increased RBC =compensatory due to O2 supply=viscous blood =thrombus = embolus = stroke

3.

ECG – cardiomegaly Cardiac cath – decreased O2 saturation Palliative repair – rashkind procedure Complete repair – mustard repair

2.) Total Anomalous Pulmonary venous return – pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC Increased pressure on Rt so blood goes to Lft Outstanding Sx: Open foramen ovale Mild to moderate cyanosis Polycythemia = thrombus = embolus = stroke

asplenia- absent spleen Mgt: restructuring of heart 3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 1 single vessel or common trunk with VSD S & Sx 1. cyanosis 2. polycythemia – thrombus = embolus = stroke Mgt: Heart transplant 4.) Hypoplastic Left heart syndrome – non fx Left ventricle 1. cynosis 2. polycythemia – throm, emb, stroke Mgt: heart transplant

5.) Tricuspid atresia – failure of tricuspid valve to open S&SX: open foramen ovale (R to L shunting – goes to Lt atrium) cynosis, polycythemia Mgt: fontan procedure – open tricuspid valve 6.) Tetralogy of Fallot P – pulmonary stenosis V – ventricular SD O – overriding or dextroposition of aorta R – Rt ventricular hypertrophy S &Sx: 1. 2. 3. 4. 5. 6. 7.

Rt ventricular hypertrophy high degree of cyanosis polycythemia severe dyspnea – squatting position – relief , inhibit venous return facilitate lung expansion. growth retardation – due no O2 tet spell or blue spells- short episodes of hypoxia syncope

8. clubbing of fingernails – due to chronic tissue hypoxia 9. mental retardation – due decreased O2 in brain 10. boot shaped heart – x-ray Mgt: 1. 2. 3. 4. 5.

O2 no valsalva maneuver , fiber diet laxative morphine – hypoxia propranolol – decrease heart spasms palliative repair – BLT blalock taussig procedure Brock procedure – complete procedure

ACQUIRED HEART DSE 1. RHD Rheumatic Heart Disease - inflammation disease ff an infection acquired by group A Beta hemolytic strepto coccus Affected body – cardiac muscles and valves , musculoskeletal , CNS, Integumentary Sorethroat before RHD Aschoff – rounded nodules with nucleated cells and fibroblasts – stays and occludes mitral valve.

Jones Criteria Major

Minor

1. polyarthritis – multi joint pain

1. arthralgia – joint pain

2. chorea – sydenhamms chores or

2. low grade fever

st. vetaus dance-purposeless involuntary hand and shoulder with grimace 3. carditis – tachycardia

3. all lab results

erythema marginatum - macular rashes

increase antibody

SQ nodules

" C reactive protein " erythrocyte sedimentation rate " anti streptolysin o titer (ASO)

Criteria:Presence of 2 major, or 1 major and 2 minor + history of sore throat will confirm the dx. Nsg Care: 1. 2. 3. 4.

CBR throat swab – culture and sensitivity antibiotic mgt – to prevent recurrence aspirin – anti-inflammatory. Low grade fever – don’t give aspirin. S/E of aspirin:

•

Reyes syndrome – encephalopathy- fatty infiltration of organs such as liver and brain

Respiration Newborn resp – 30-60 cpm, irregular abd or diaphramatic with short period of apnea without cyanosis. < 15 secs – normal apnea –newborn Resp Check Newborn – 40 – 90 1 yr - 20 – 40 2-3yr 20 – 30 5 yrs 20 – 25 10 yrs 17 – 22 15 & above 12- 20 BREATH SOUNDS HEARD DURING ASCULTATION: 1.) VESICULAR – soft, low pitched, heard over periphery of lungs, inspiration longer then expiration -Normal

2.) BRONCHOVESICULAR- soft, medium pitched, heard over major bronchi, inspiration equals exp. Normal 3.) BRONCHIAL SOUNDS- loud high pitched, heard over trachea, expiration longer than inspiration. Normal 4.) RHONCHI – snoring sound made by air moving through mucus in bronchi. Normal 5.) RALES-or crackles – like cellophane – made by air moving through fluid in alveoli. Abnormal- asthma, foreign body obstruction. 6.) WHEEZING- whistling on expiration made by air being pushed through narrowed bronchi .Abnormal – asthma, foreign body obstruction 7.) STRIDOR- crowing or ropster life sound – air being pulled through a constricted larynx. Abnormal – resp obstruction Asthma- pathognomonic sign – expiratory wheezing Pet – fish. Sport – swimming Drugs – amynophylline – monitor bp, may lead to hypotension Laryngo Tracheo Bronchitis LTB - inspiratory stridor – pathognomonic sign RDS respiratory dist synd or hyaline membrane dis Cause- lack of surfactant – for lung expansion Hypotonia, Post surgery, Common to preterm Fibrine hyaline Sx – definite with in 1st of life Increase RR with retraction Inspiratory grunting – pathognomonic 7 – 10 severe RDS (silvermenn Anderson index) cyanosis due to atelectasis Mgt: 1. 2. 3.

surfactant replacement and rescue pos- head elevated proper suctioning

4. 5. 6. 7.

o2 with increase humidity- to prevent drying of mucosa monitor V/S skin color , ABG CPAP- continuous + a/w pressure PEEP - + end expiratory pressure Purpose of #6-7- to maintain alveoli partially open and alveoli collapse

LARYNGOTRACHEOBRONCHITIS LTB – most common Creup -viral infection of larynx, trachea & bronchi outstanding sx - croupy cough or barking pathognomonic - stridor • • •

labored resp resp acidosis end stage – death

Lab: 1. 2. 3.

ABG neck and throat culture dx- neck x-ray to rule out epiglotitis

Nsg Mgt: 1. bronchodilators 2.increase o2 with humidity 3. prepair tracheostomy set BRONCHOLITIS- Inflammation of bronchioles – tenatious mucus Causative agaent – RSV - Resp sincytial viruses Sx: flu like sx Increased RR Drug: Antiviral – Ribavirin End stage – epiglotitis

EPIGLOTITIS - infl of epiglottis - emer. Condition of URTI

Sx: sudden onset Tripod position – leaning forward with tongue protrusion •

never use tongue depressor

prepare tracheotomy set < 5 yo – unable to cough out, put on mist tent (humidifier o2) or croupe tie Nsg Care: check edges tucked on mist tent Provide washable plastic material No toys with friction due O2 on No hairy toys – due moist environment medium for bacterial growth BP – 80/46 mmHg newborn BP after 10 days- 100/50 BP taking begins by 3 yo COA – take BP on 4 extremities SKIN: Acrocyanosis BIRTHMARKS: 1. 2. 3. 4. 5.

Mongolian spots – stale gray or bluish discoloration patches commonly seen across the sacrum or buttocks due to accumulation of melanocytes. Disappear by 1 yr old MIlla – plugged or unopened sebaceous gland . white pin point patches on nose, chin or cheek. Lanugo – fine, downy hair – common preterm Desquamation – peeling of newborn, extreme dryness that begin sole and palm. Stork bites (Talengeictasi nevi) – pink patches nape of neck 

hair will grow as child grows old

1. Erythema Toxicum – (flea bite rash)- 1st self limiting rash appear sporadically & unpredictably as 2.

to time & place. Harlequin sign – dependent part is pink, independent part is blue (side lying – bottom part is dependent pink)

3. 4.

Cutis Marmorato – transitory mottling of neonates skin when exposed to cold. Hemangiomas – vascular tumors of the skin

3 types Hemangiomas

a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgically b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges, disappears at 10 yo. c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age. - MOST DANGERIOUS – intestinal hemorrhage Skin color blue – cyanosis or hypoxia White – edema Grey – inf Yellow – jaundice , carotene Vernix Caseosa – white cheese like for lubrication, insulator BURN TRAUMA – injury to body tissue caused by excessive heat. INFANT ANTERIOR

5-9 yo

POSTERIOR

Ant

Post

Head

9.5

9.5

6.5

6.5

Neck

1

1

1

1

Upper arm

2

2

2

2

Lower arm

1.5

1.5

1.5

1.5

Hand

13

1.25

1.25

1.25

Trunk

13

13

Back

13

13

Genital

1

1

@ buttocks

2.5@

2.5 @

Thigh

2.75

2.75

4

4

Leg

2.5

2.5

3

3

foot

1.75

1.75

1.75

1.75

DEPTH 1st degree – partial thickness – superficial epidermis - erythema, dryness, PAIN -sunburn, heals by regeneration from 1 – 10 days 2nd degree – epidermis & dermis- erythema, blisters, moist, extremely painful o

scalds

3rd degree – full thickness- epidermis, dermis, adipose tissue, fascia, muscle & bone o o

lethargy, white or black, not painful – nerve endings destroyed ex. lava burns

Mgt: 1.) 1st aid a.) put out flames by rolling child on blanket b.) immerse burned part on cold H2o c.) remove burned clothing of with sterile material d.) cover burn with sterile dressing 2.) a/w a.) suction PRN, o2 with increased humidity b.) endotracheal intubation c.) tracheostomy 3.) Preventiuon of shock & F&E imbalance a. colloids to expand bld volume b. isotonic saline to replace electrolytes c. dextrose & H2o to provide calories 4.) Tetanus toxoid booster 5.) Relief of pain – IV analgesic MORPHINE SO4 – needed for 2nd degree – very painful 6.) 1st defense of body – intact skin prevention of wound infection

a. b. c.

cleaning & debriding of wound open or close method of wound care whirlpool therapy – drum with solution

7.) skin grafting – 3rd degree – thigh or buttocks (autograft), pigs/ animals – xenograft frozen cadaver – hallow graft 8,) diet – increase CHON, increase calories. ATOPIC DERMATITIS- infantile eczema (galis) Papulo vesicular erythematus lesions with weeping & crusting Cause – food allergies: milk, citrus juice, eggs, tomatoes, wheat Sx: - extreme pruritus, linear excoriation, weeping crusting; scaly shiny and white – lechenification Goal of care: decrease pruritus – avoid food allergens Diet: Prosobi or Isomil Hydrate skin, borow solution 1% hydrocortisone cream Prevent infection – proper handwahsing, trim nails IMPETIGO- skin disease. Causative agent – grp A beta Hemolytic streptococcus •

papulovesicular surrounded by localized erythema –becomes purulent , oozes a honey colored crust

Pediculosiscapitis –"KUTO" •

Mgt: proper hygiene – wash soap and H2o, oral penicillin – bactroban ointment Can lead to acute glomerulonephritis AGN

ACNE- adolescent problem • •

self limiting infl dis – sebaceous gland comedones – sebum causing white heads sebum- lipids causing acne bulgaris

Mgt: - proper hygiene- mild soap or sulfur soap- antibacterial retin A or tretinoi

ANEMIA-pallor Causes: 1.)early cutting of cord – preterm – cut umb cord ASAP fullterm – cut umb cord when pulsation stops 2.) Bleeding disorders – blood dyscrasias HEMOPHILIA – deficiency of clotting factor. X linked recessive – inherited If mom – carrier, son – affected If father carrier- transmitted to daughter Hemophilia A – deficiency of coagulation component factor 8 Hemophilia B –or christmas disease, deficiency of clotting factor 9 Hemophilia C – deficiency of clotting factor 11 Assessment: • • • •

umphalagia – earliest sign newborn receive maternal clotting factor newborn growing – sudden bruising on bump area- marks earliest sign continuous bleeding – hematrosis – damage or bleeding synovial membrane

Dx test : PTT. Partial thromboplastin time – reveals deficiency in clotting factor Long Term Goal- prevention of injury Nsg Dx- increase risk of injury HT: avoid contact sport, swimming only, don’t stop immunization – just change gauge of needle Falls – immobilized , elevate affected part, apply pressure-not more then 10 min cold compress -determine case before doing invasive procedure LEUKEMIA- grp of malignant disease • •

rapid proliferation of immature WBC WBC – protection from infection, soldiers of body

Classification :

1. 2. 3. 4.

Lympho – affects lymphatic system Myelo – affects bone marrow acute / blastic- affects immature cells chronic/ cystic- affects mature cells

MOST COMMON CANCER – (ALL) – Acute Lymphocytic Leukemia S&Sx: 1. from invasion of bone marrow signs of infection a. b. c.

fever poor wound healing bone weakness & causes fracture

signs of bleeding a. b. c.

petecchiae-small, round, flat, dark red spot epistaxis blood in urine/ emesis

signs of anemia a.

pallor , body malaise , constipation

2. from invasion of body organ- hepato spenomegaly – abd pain , CNS affectation, increase ICP Dx Tests: 1. 2.

4.

PBS- peripheral blood smear – determine immature RBC CBC – determine anemia, leukocytosis, thrombocytopenia neutropenia lumbar puncture (LP) – determine CNS involvement. Before LP, fetal pos.- avoid flexion of neck – will cause a/w obstruction."C" position or shrimp position only. bone marrow aspiration – determine blast cells,

• •

common site- iliac crest post BMA s/effect –

3.

bleeding •

apply pressure. Put pt on affected side to prevent hemorrhage

1. 2.

Bone scan – determine bone involvement CT scan – determine organ involvement

Therapeutic Mgt: TRIAD: 1. 2. 3.

surgery irradiation chemotheraphy Focus Nsg Care: prevent infection

4 LEVELS OF CHEMOTHERAPHY 1. induction – goal of tx; to achieve remission meds: IV vincristine L- agpariginase Oral predinisone 2. Sanctuary- treat leukemic cells that invaded testes & CNS give: methotrixate- adm intrathecally via CNS or spine cytocine, Arabinoside, steroids with irradiation 3. maintenance- to continue remission give: oral methotrisate – check WBC -adm of methotrisate – do weekly WBC check 4. Reinductin – treat leukemic cells after relapse occurs. Meds – same as induction - give antigout agents: allopurinol or Zyloprim- treat or prevent hyperurecemic nephropathy. Nsg mgt: Outstanding nsg dx: alteration in nutrition less body requirement. Based on Maslow’s heirarchy S/Effect of Chemotherapy 1. N/V – adm antiemetic drugs 30 mins before chemo until 1 day after chemo 2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration nutrition less body req) - oral care – alcohol free mouthwash , betadine mouthwash - don’t brush – use cotton pledgets

- topical xylocaine before meals diet- soft, bland diet according to child’s preference Temporary S/E of chemo: Alopecia – altered body image Hirsutism – hair -give emotional support to parents ABO incompatibility – Most common incompatibility – ( mom) O – ( fetus) A Most severe incompatibility (Mom) O– (Fetus) B Can affect 1st pregnancy

Hydrops (h20) Fetalis – edematous on lethal state with pathologic jaundice Within 24 h Mgt: 1. 2.

initiate breastfeeding to get colostrum Temp suspension of breastfeeding

•

content breast milk pregnanedioles – that delays action of glucoronil transferees liver enzymes converts in direct bilirubin to become direct bilirubin

1. 2.

Needs phototherapy needs exchange therapy

Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term

Normal – 0-3 mg/dL • •

bilirubin encephalopathy Kemicterus - > 20 mg/dL among full term & >12 mg /dl of indirect – preterm =can lead to cerebral palsy-

Physiologic jaundice – jaundice within 48 -72 h (2-3 days) expose morning sunlight Pathologic Jaundice – within 24h. Jaundice during delivery. Breastfeeding jaundice – caused by pregnanediole Assessment of Jaudice : 1. Blanching neonates forehead, nose or sternum - yellow skin & sclera - color of stool – light stool - color of urine – dark urine Mgt: Phototheraphy – photo oxygenation Nsg Resp: 1. 2. 3. 4. 5. 6.

cover eyes – prevent retinal damage cover genitals – prevent priapism – painful continuous erection change position regularly – even exposed to light increase fld intake – due prone to dehydration monitor I&O – weigh baby monitor V/S – avoid use of oil or lotion due- heat at phototherapy = bronze baby syndrome-transient S/E of phototherapy

weigh diaper 1gm = 1cc Head – largest part of baby ¼ of its length Craniostenosis or craniosinustosis – premature closing of fontanel Hydrocephalus – ant fontanel open after 18 mos Microcephaly – small growing brain due- alcohol & HIV mom Anencepahly – absence of cerebral hemisphere

Craniotabes – localized softening cranial bone. Common – 1st born child -due early lightening (2 weeks prior to EDD) Rickets of Vit B deficiency – soft cranial bone in older children Caput Succedaneum – edema of scalp due prolonged pressure at birth Char: 1. 2. 3.

present at birth crosses suture lines disappear after 2-3 days

Cephalhematoma- collection of blood due to rapture of pericostal capillaries Char : 1. 2. 3. 4.

present after 24 h never cross suture line disappear after 4-6 weeks monitor for developing jaundice

Seborrheic Dermatitis – ‘craddle cap" Scaling, greasy appearing salmon colored patches – seen on scalp behind ears and umbilicus Cause: - improper hygiene Mgt: 1. 2.

proper hygiene put oil night before shampoo

•

baby oil

Hydrocephalus – excessive accumulation of CSF 1. 2.

communicating – extra ventricular hydrocephalus non-communicating- intraventricular hydrocephalus or obstructive hydrocephalus due to tumor obstruction

Sx – ICP – abnormally large head, bulging fontanel •

cushings triad

•

high pitched cry

older child – diplopia – eye deviation, projectile vomiting • • •

fontanel bossing – prominent forehead - prominent skull vein sunset eyes

Mgt: position to lessen ICP – low semi-fowlers 30 degree angle Administer- osmotic diuretic Mannitol/ Osmitrol , Diamex- Azetam Decrease CSF production Shunting – AV shunt or Vp shunt (ventriculoperitoneal shunt) Shave hair – in OR – to prevent growth of micro org. Nsg Care: 1.) post VP shunt – side lying on non operated site - to prevent increase ICP monitor for good drainage - sign – sunken fontanel bulging fontanel – blocked shunt change fontanel as child is growing SENSES EYES: Assessment 1. 2.

check for symmetry sclera – normal color – light blue then become dirty white pupil – round- adult size coloboma- part of iris is missing sign: key hole pupil

whiteness & opacity of lens congenital cataract cornea – round & adult size large – congenital glaucoma Test for blindness common tests

1. newborn – general appearance - can only see 10 – 12 " - visual acuity 20 /200 to 20/ 800 Doll’s eyes test- test for blindness • •

done 10th day pupil goes opposite to direction when head is moved

Globellars test – test for blink reflex. Points near nose – baby should blink

2. Infant & children - appearance - ability to follow object past midline 3. 3 yrs – school age - general appearance Allen cards – test for visual acuity. Show picture 20 ft away Ishiharas plates – test for color blindness Prechool E chart - test for stereopsi of depth perception Cover testing test – cover 1 eye for 10 – 15 min. Then remove. Test for strabismus 4. School age – adult - general appearance - snellens test Retinobastoma – malignant tumor of retina Outstanding sign : oat’s eye reflex-whitish glow of pupil • •

red painful eye blindness

surgery – Enucliation – removal of eyeball put artificial aye NOSE:

1. 2.

flaring alenase – case of RDS cyanosis at rest – choanal atresia - post nares obstructed with bone or membrane

1. 2.

resistance during catheter insertion emer. Surgery within 24 h

Sx:

normal color nasal membrane – pinkish rhinitis – presence of creases & pale check sense of smell – blindfold – smell Hair in nose – cilia Adolescent no hair with ulceration of nasal mucosa suspect cocaine user Epistasis – nosebleed • •

sit upright, head slightly forward to facilitate drainage cold compress , apply gentle pressure, epinephrine

most developed sense of newborn – sense of touch 1st sense to develop & last to disappear – hearing EARS: 1.

Properly aligned with outer cantus of eyes

low set ear – kidney malformation ex. Renal aginesis – absence of kidney sign in uterus : oligohydramnios sign in newborn: 2 vessel cord failure to void within 24 h Mgt: kidney transplant

Chromosomal aberrations : -advance maternal age 1. non disjunction – uneven division Trisomy 21 - down syndrome - extra chromosome 47xx + 21 - related to advance paternal age Sx: Mongolian slant Broad flat nose Protruding neck Puppy’s neck Hypotonic – prone to resp problem Simean crease – single transverse line on palm. Trisomy 18 – "endvard syndrome" Trisomy 13- patau syndrome Turner – Monosomy of X synd. • • • • •

45x0 affected girls signs evident during puberty has poorly developed 2dary sexual char. Sterile

Klinefelters Syndrome- has male genitalia - 47 XXY - poorly devt secpndary sexual characteristics - no deepening of voice -small testes, penis -sterile Klinefelter – Calvin Kline – male Turner – Tina Turner – female

Otitis Media – inflammation of middle ear. Common children due to wider & shorter Eustachian tube Causes 1. 2.

bottle propping Cleft lip/ cleft palate –

Sx: Otitis 1. 2. 3. 4.

bulging tympanic membrane, color – pearly gray absence light reflex observe for passage of milky, purulent foul smelling odor discharge observe for URTI

Nsg Care: 1. 2.

position side lying on affected aside – to facilitate drainage supportive care- bedrest, increase fld intake

Med Mgt: 1. Massive dosage antibiotic Complication – bacterial meningitis 2. Apply ear ointment School age – up and down < 3 yo – down & back > 3 yo – up & back Small child – down & back ( no age) surgery (to prevent permanent hearing loss)– otitis media – myringotmy with tympanostomy tube post surgery – position affected side for drainage both – put ear plug if tympanous tube falls – healed na Bells Palsy- facial nerve #7 paralysis R/T forcep delivery Sx. 1. 2.

Continuous drooling saliva inability to open , eye & close either eye

Mgt: Refer to PT TEF (Tracheoesophageal Fistula)-TEA- no connection bet esophagus and stomach Outstanding Sx – Coughing Choking Continuous drooling Cyanosis Mgt: Emergency surgery Epstein pearl – white glistering cyst at palate & gums related to hypercalcemia Hypervitaminosis Natal tooth – tooth at birth. Move with gauze Neonatal tooth – tooth within 28days of life Moniliasis – oral candidiasis • • •

white cheese like, curd like patches that coats tongue oral thrush Nsg Care – don’t remove, wash with cold boiled H2o

Meds – nystatin / Mysnastatin – antifungal Kawasaki Dse--strawberry tongue - originated in Korea - Dr. Kawasaki discovered it - common in Japan - "mucocutaneous Lymphnode Syndrome" Sx: -persistent fever – 5 days -strawberry tongue , -desquamation of palm & sole

- lymph adenopathy > 1.5 cm Drug: aspirin Can lead to MI LIPS- symmetrical Cleft lip – failure of median maxillary nasal process to fuse by 5-8 wks of pregnancy • •

common to boys unilateral

Cleft Palate- Failed palate to fuse by 9 – 12 wks of pregnancy • •

common to girls unilateral or bilateral

1. 2. 3.

evident at birth milk escapes to nostril during feeding frequent colic & otitis media or URTI

Sx:

Mgt: 1. Surgery cleft lip repair – Cheiloplasty =done 1-3 months to save sucking reflex (lost in 6 months ) Cleft Palate- uranoplasty = done 4-6 months to save speech Pre op care 1. 2. 3.

emotional support especially to mom proper nutrition prevent colic feed – upright seating or prone pos burp frequently 2x at middle and after feeding-lower to upper tap

4.

orient parents to type of feeding rubber tipped syringe – cheiloplasty paper cup/ soup spoon/ plastic cup – urano plasty

5.

apply restraints – elbow restraints so baby can adjust post op

Condition that warrants suspension of operation •

colds & pharyngitis = can lead to generalized infection – septicemia

Post Op Nsg Care : 1. airway – positon post cheilopasty – side lying for drainage post uranoplasty (tonsillectomy)- prone 2. assess for RDS sx bleeding 3. assess for bleeding – freq swallowing. 6-7 days after surgery – bleeding 4. proper nutrition • •

clear liquids- ( gelatin except red or brown color due may mask bleeding) ( popsicle- not ice cream) full liquid soft diet regular diet

5. Maintain integrity of suture line such as: Logan bar – wash ½ strength Hydrogen Peroxide & saline solution- Bubbling effect traps microorganism - prevent baby form crying for pain- analgesic

NECK1.

check symmetry

Congenital torticolis- " wryneck"-burn injury of sternocleidomsstoid muscle during delivery – due to excessive traction at cephalic delivery Mgt: passive stretching exercise , Surgery Complication – scoliosis THYROID gland – for basal metabolism

Congenial cretinism – absence or non functioning thyroid glands reasons for delaying dx: 1. 2. 3.

Thyroid glands covered by sternocleidomastoid muscles in newborn baby received maternal thyroxine baby sleeps 16 – 20 h a day

earliest sign: 1. 2. 3. 4. 5.

change in crying change in sucking sleep excessively constipation edema – moon face

late sign 1.

mental retardation

prognosis : mental retardation preventable when Dx is early Dx: 1. 2. 3.

PPI-protein radioimmunoassay test radioactive iodine uptake

Mgt: synthroid – sodium Levothyrosine -synthetic thyroid given lifetime • •

check pulse rate before giving synthroid tachycardia – Sx of hyperthyroidism

CHEST 1. 2.

symmetry breast - transparent fluid coming out from newborn related to hormonal changes3. chest has retroactive – RDS 4. sternum sunken – pectus excavation

ABDOMEN (in order) 1. 2. 3. 4.

inspection I Auscultation A percussion P Palpation P = Will change bowel sounds, so do last Normal contour of abd – slightly protruding

Sunken abd- diaphramatic hernia – protrusion of stomach content through a defective diaphragm due to failure of puroperitoneal canal to close. Sx: 1. 2. 3.

sunken abd Sx of RDS R to L shunting

Mgt: Emergency surgery within 24h Omphalocele – protrusion of stomach contents in between junction of abd wall and umbilicus. Mgt- very small surgery If large – suspension surgery Nsg Mgt: protect sac- sterile wet dressing Gastrochisis – absence of abd wall Nsg Mgt: sterile wet dressing Fx of GIT 1. 2. 3.

assists in maintaining F&E & acid base balance Processes & absorbs nutrients to maintain metabolism & support G & D excrete waste products from digestive process

Recommended Daily Allowance Calories : 120 cal / Kbw/day (kilo body wt) 360 – 380 cal/ day CHON_ 2.2g /Kbw/day Principles in Supplementary Feeding Supplementary Feeding usually – 6 mos Supplementary feeding given – 4 mos. a.) solid food offered to ff sequence! 1. cereals – rich in iron

2. fruits 3. veg 4. meat b.) begin with small quantities c,) finger foods – offered 6 months d.) soft table food – "modified family menu" given 1 yr e.) dilute fruit juices – 6 mos f.) never give half cooked eggs – usually causes of salmoneliosis g.) don’t give honey – infant botulism h.) offered new food one at a time – interval of 4 – 7days or 1 week – determines food allergens Total Body Fluids- comprises 65 - 85% of body wt of infants & children Where fluids are greater in infants Extracellular fld – prone to develop dehydration Acid Base Balance dependent on the ff: a. b. c.

chemical buffers renal & resp system involvement dilution of strong acids and bases in bld

Resp Acidosis – carbonic acid excess • • • •

hypoventilation RDS COPD Laryngotracheobronchitis (LTB)

Resp Alkalosis – carbonic acid deficit • • •

hyperventilation fever encephalopathy

Met. Acidosis – base HCO3 deficit • • •

diarrhea severe dehydration malnutrition

•

ciliac crisis

Met Alkalosis – base HCO3 excess • • •

uncontrolled vomiting NGT aspiration Gastric lavage

PROBLEMS LEADIING TO F&E IMBALANCE 1. vomiting – forceful expulsion of stomach content Sx: 1. 2. 3. 4.

nausea dizziness facial flushing abd cramping

assess: amt, freq, force projectile vomiting= increase ICP or pyloric stenosis Mgt: BRAT diet - banana, rice – cereal, apple sauce, toast 2. Diarrhea – exaggerated excretion of intestinal contents Types: Acute diarrhea – related to gastroenteritis, salmoneliosis • •

dietary indiscretions antibiotic use

Chronic non specific diarrhea Cause: 1. 2. 3.

food intolerance excessive fld intake CHO, CHON malabsorption

Assess: freq, consistency, appearance of given colored stool.

Best criteria to determine diarrhea : consistency Complication = dehydration Mild dehydration 5% wt loss Moderate dehydration 10% wt loss Severe dehydration 15 % wt loss Earliest sx of dehydration tachycardia increase temp weight loss tachypnea sunken fontanel & eyeballs scanty urine hypotension absence of tears Severe dehydration: Oliguria , Prolonged capillary refill time Mgt: Acute – NPO ( rest the bowel ) • •

with fluid replacement – IV prone to Hypokalemia – give K chloride before adm of K chloride – check if baby can void, if cant void – hypokalemia

Drug: Na HCO3 – adm slowly to prevent cardiac overload

Gastric Motility Disorder: HIRSCHPRUNGS DISEASE – congenital aganglionic megacolon Aganglionic – absence of ganglion cells needed for peristalis Earliest sign 1. 2. 3.

failure to pass mecomium after 24h abd distension vomitus of fecal material early childhood – ribbon like stool foul smelling stool

constipations diarrhea Dx: 1. 2. 3. 4.

Barium enema – reveals narrowed portion of bowel Rectal Biopsy – reveals absence of ganglionic cells abd x-ray – reveals dilated loops on intestine rectal manometry – revels failure of intestine sphincter to relax

Therapeutic Mgt/Nsg care 1. 2.

NGT feeding – measure tube fr nose to ear to midline of xyphoid & umbilicus surgery

a. b.

temp colostomy anastomosis & pull through procedure Diet: Increase CHON, increase calories , decrease residue – pasta GER- Gastroesophageal Reflux Chalasia – presence of stomach contents to esophagus Will lead to esophagitis complication – aspiration pneumonia

Esophageal cancer Assessment : 1. 2. 3. 4.

chronic vomiting faiture to thrive syndrome organic – organ affected melena or hematemesis – esophageal bleeding

Dx procedure 1. 2. 3.

barium esophogram – reveals reflux esophageal manometry – reveals lower esophageal sphincter pressure intra esophageal pH content – reveals pH of distal esophagus.

Meds of GERD

Anti-cholinergic a. b.

Betanicol ( urecholine) – increase esophageal tone & peristaltic activity Metachloporomide (Reglam) – decrease esophageal pressure by relaxing pyloric & duodenal segments

•

increase peristalsis without stimulating secretions

a.

H2 Histamine Receptor Antagonist – decrease gastric acidity & pepsin secretion

•

Zimetidine, Ranitidine (Zantac) – take 30 min before meals

a.

antacid – neutralizes gastric acid between feedings - Maalox

Surgery: Nissen funduplication : Chronic vomiting – • • •

thickened feeding with baby cereals - effective if without vomiting feed slowly, burp often every 1 ounce positioning < 9 months – infant sit with infant supine > 9 months – prone with head of mattress slightly elevated 30 degree angle

OBSTRUCTIVE DISORDERS A. PYLORIC STENOSIS – hypertrophy of muscles of pylorus causing narrowing & obstruction. 1.) outstanding Sx- projectile vomiting - vomiting is an initial sx of upper GI obstruction - vomitus of upper GI can be blood tinged not bile streaked. (with blood) - vomitus of lower GI is bilous ( with pupu) - projectile vomiting – increase ICP or GI obstruction - abd distension – major sx of lower GIT obst 2.) met alk 3.) failure to gain wt 4.) olive shaped mass – on palpation

5.)serum electrolyte – increase Na & K, decrease chloride 6.) ultrasound 7.) x ray of upper abd with barium swallow reveal "string sign" Mgt: 1. 2.

Pyleromyotomy Fredet Ramstedt procedure

INSTUSSUSCEPTION- invagination or telescoping of position of bowel to another Common site – ilio-secal junction Prone pt: person who eats fat Complication – peritonitis – emergency Sx: 1. 2. 3.

persistent paroxysmal abd pain vomiting currant jelly stool- dye bleeding & inflammation

•

palpate sausage shaped mass

Mgt: 1. 2.

Hydrostatic reduction with barium enema Anastomosis & pull thru procedura

Inborn Errors of Metabolism- deficient liver enzymes PHENYLKETONURIA (PKU) – deficiency of liver enzymes (PHT) Phenylalaninehydroxylase Transferase – liver enzyme that converts CHON to amino acid 9 amino acids: valine isolensine tryptophase lysine phenylalanine Thyronine – decrease malanine production 1. 2. 3.

fair complexion blond hair blue eyes

Thyroxine – decrease basal metabolism - accumulation of Phenyl Pyruvic acid 4.) Atopic dermatitis 5.) musty / mousy odor urine 6.) seizure – mental retardation Test – GUTHRIE TEST – specimen – blood • •

preparation increase CHON intake test if CHON will convert to amino acid

specimen and urine mixed with pheric chloride, presence of green spots at diaper a sign of PKU DIET: Low phenylalanine diet- food contraindicated- meats, chicken, milk, legumes, cheese, peanuts Give Lofenalac- milk with synthetic protein Galactosemia – deficiency of liver enzyme • •

GUPT – Galactose Urovil Phosphatetranferase Converts galactose to phosphate tranferace glucose

Galactose – will destroy brain cells if untreated – death within 3 days Dx: Beutler test – get blood -done after 1st feeding presence of glucose in blood – sign of galactosemia galactose free diet lifetime neutramigen – milk formula CELIAC DISEASE – gluten enteropathy Common gluten food: Intolerance to food with brow B- barley

R- rye O- oat W- wheat Early Sx: 1. 2. 3.

diarrhea – failure to gain wt ff diarrheal episodes constipation vomiting

Late Sx: 1. 2.

abd pain – protruberant abd even if with muscle wasting steatorrhea

Celiac Crisis- exaggerated vomiting with bowel inflammation Dx: 1. 2.

lab studies – stool analysis serum antiglyadin – confirmatory of disease

gluten free diet – lifetime all BROW – not allowed ok – rice & corn Mgt: 1. 2. 3.

vitamin supplements mineral supplements steroids