Deck 3

Question 1

S E P S I S
Therapeutic management

Answer 1

-Aggressive approach
-Close monitoring
-Antibiotic therapy (after blood, urine, and CSF cultures are obtained)
-Management of shock will be done in the intensive care unit

Question 2

S E P S I S
Nursing assessments

Answer 2

-Signs of sepsis may be vague (not acting right, tired, uninterested)
-Note reaction to parents, lack of smiling, lack of responsiveness
-Inspect skin for rashes
-Observe respiratory efforts
-Assess vital signs - hypotension may indicate shock

Question 3

S E P S I S
Laboratory and Diagnostic Tests

Answer 3

-CBC
-CRP
-Cultures
-Chest x-ray

Question 4

S E P S I S
Nursing management

Answer 4

-Monitor for changes, particularly the development of shock
-Prevent infection- hand washing, cleaning equipment, sterile procedures, immunizations
-Education- parents should be educated about the significance of a fever, especially for infants younger than 3 months

Question 5

Oral Candida (thrush)

Answer 5

-Fungal infection of the oral mucosa
-Risk factors: Children with immune disorders using corticosteroid inhalers, suppressed immunity (chemo)
Treatments: Antibiotics, antifungal agents (oral), nystatin & fluconazole
-Can be transmitted between the infant and the breastfeeding mother. If mom is infected, she must be treated as well. Keep both bottle nipple and mom nipple clean
-Inspect for white patches on tongue, mucosa, or palate that do not easily wipe off, check for diaper rash

Question 6

Structural Anomalies of the GI Tract
Cleft Lip & Palate

Answer 6

-Most common craniofacial anomaly
-Complications include difficulty feeding, altered dentition, delayed speech development, and otitis media
-Develops in early pregnancy when the lip or palate does not fuse
-Typically managed by plastic surgeons, craniofacial specialists, oral surgeons, dentist, psychologist, otolaryngologist, nurse, social work, audiologist, speech-language pathologist

Question 7

Dehydration

Answer 7

Early recognition and treatment is critical to prevent hypovolemic shock
-Risk factors: diarrhea, vomiting, decreased oral intake, sustained high fever, DKA, extensive burns

Question 8

Management for dehydration

Answer 8

Initially, 20ml/kg of NS or LR
-IVF at maintenance rate or 1.5x maintenance rate
-Continuously reassess hydration status

Question 9

Acute Gastrointestinal Disorders
Intussusception

Answer 9

Occurs when a proximal segment of the bowel “telescopes” into a more distal segment, causing edema, vascular compromise, and partial or total bowel obstruction
-Typically, symptoms flare then regress. Children may have no episodes between episodes.
-A barium enema is successful at reducing a large amount of cases, other cases are reduced surgically
-If bowel necrosis occurs, a portion of the bowl must be resected.
-Signs and symptoms: sudden onset of crampy abdominal pain, severe pain (knees to chest), vomiting, diarrhea, currant-jelly stools, lethargy, sausage-shaped mass in upper mid-abdomen
- IV fluids and antibiotics

Question 10

Acute Gastrointestinal Disorders
Appendicitis

Answer 10

-Acute inflammation of the appendix due to a closed-loop obstruction
-Most common cause of emergent abdominal surgery in children
-Due to fecal matter in the appendix, perforation causes inflammatory fluid and bacterial contents to leak into the abdominal cavity, resulting in peritonitis.
-Considered a surgical emergency
-signs and symptoms: abdominal pain, N/V, low-grade fever (unless perforation occurs), tenderness over McBurney’s point (RLQ)
-Sudden relief without intervention suggest perforation, notify physician immediately!
-Routine post-op care requires antibiotics, but a child with a perforated appendix may require 7-14 days of IV antibiotic therapy

Question 11

Acute Gastrointestinal Disorders
Gastroesophageal Reflux Disease (GERD)

Answer 11

-Passage of gastric contents into the esophagus (GER)
-When the reflux of gastric contents back into the esophagus or oropharynx, it becomes more of a pathologic process known as GERD
-signs and symptoms of GERD are often seen as a result of the damaging components of refluxate.
-GERD may cause esophagitis, esophageal stricture, Barrett esophagus, anemia from chronic esophageal erosion
-Recurrent pneumonia, laryngitis, or asthma may occur
-Conservative medical management (positioning, keeping child upright after a feed)
-If conservative measures are not successful, medications are prescribed that reduce the acid production and stabilize the pH of the gastric contents
-Nissen fundoplication is the most common surgical procedure for GERD
-The gastric fundus is wrapped around the lower 2-3cm of the esophagus
-Remember: maximize reflux precautions to keep the risk of airway involvement to a minimum

Question 12

Chronic Gastrointestinal Disorders
Hirschsprung Disease (Congenital Aganglionic Megacolon)

Answer 12

-Caused by the lack of ganglion cells in the intestine, which leads to inadequate motility in part of the intestine
-Characterized by failure to pass stool (meconium) within the first 24 hours of life
-Requires surgical resection of aganglionic bowel and reanatomosis of the remaining intestine
-Surgery is performed in stages and the child will have a temporary ostomy
-Rectal exams- when finger is withdrawn, there may be a forceful expulsion of fecal material
-Watch for enterocolitis (fever, ab distention), report signs to provider immediately

Question 13

Chronic Gastrointestinal Disorders
Celiac Disease

Answer 13

-Immunologic disorder in which gluten causes damage to the small intestine
-Gluten-free diet allows villi of the intestines to heal and function normally
-signs and symptoms: diarrhea, fatty stools, constipation, FTT/weight loss, abdominal distention or bloating, poor muscle tone, irritability, dental disorders, anemia, delayed onset of puberty or amenorrhea, nutritional deficiencies
-Distended stomach, wasted buttocks, very thin extremities
-Autotissue transglutaminase IgA and Antiendomysium IgA

Question 14

Hepatobiliary Disorders
Biliary Atresia

Answer 14

-An absence of some or all of the major biliary ducts, resulting in obstruction of bile flow
-Etiology unknown, believed to be infectious, autoimmune, or ischemic causes
-Kasai procedure- connects the bowl lumen to the bile duct remnants at the porta hepatis
-Infants who are not diagnosed early enough (<45 days old) or do not respond to Kasai procedure will need a liver transplant.
-Note jaundice, palpate hardened liver, note chalky/white stools, elevated bilirubin/liver enzymes/GGT, ultrasound/biliary scan/liver biopsy may be performed
-Vitamin and caloric support, administer vitamin A/D/E/K, NG feeds, manage ascites

Question 15

Acute Gastrointestinal Disorders
Hypertrophic Pyloric Stenosis

Answer 15

-The circular muscle of the pylorus becomes hypertrophied, causing thickness in the luminal side of the pyloric canal
-Causing gastric outlet obstruction, leading to vomiting between 3 & 6 weeks of life
-Vomiting becomes more frequent and forceful (projectile)
-Requires surgical intervention
-Palpate for hard, moveable “right” in the right upper quadrant, ultrasound may be needed to confirm
-Assess for dehydration from vomiting
-Post-op management focuses on fluid management and correcting electrolyte values

Question 16

Nephrotic syndrome

Answer 16

Occurs as a result of increase glomerular basement membrane permeability, which allows abnormal loss of protein in the urine
-Congenital: rare, poor prognosis
-Secondary: occurs secondary to conditions like lupus, Henoch-Schonleim purpura, or diabetes
-Idiopathic: most common type in children (minimal change nephrotic syndrome- MCNS)
-Complications: anemia, infection, poor growth, peritonitis, thrombosis, and renal failure
-Excessive albumin loss causes fluid shifts, leading to edema
-Increased risk for pneumonia, sepsis, and spontaneous peritonitis
-Observe for periorbital edema, generalized edema, ascites, taut skin, pallor, increased respiratory rate, increased work of breathing, elevated BP, auscultate for fluid overload
-Urine analysis will reveal proteinuria and mild hematuria, serum protein and albumin will be low, elevated cholesterol and triglyceride, creatinine and BUN may be elevated
-Prevent infection- immunizations, monitor temp
-Promote diuresis- steroids and diuretics
-Encourage nutrition and growth- low sodium, high protein

Question 17

Acute post-streptococcal glomerulonephritis

Answer 17

A condition in which immune processes injure the glomeruli, resulting in altered glomerular structure and function in both kidneys
-Often follows an upper respiratory or skin infection
-Complications: uremia and renal failure
-Treatment: maintaining fluid volume and managing hypertension
-signs and symptoms: fever, lethargy, headache, decreased urine output, abdominal pain, vomiting, anorexia
-Assess recent episodes of pharyngitis or other strep infections
-Assess for elevated blood pressure (common), mild edema, increased work of breathing, cough, auscultate for crackles and gallops, proteinuria, hematuria
-Administer antihypertensives, maintain sodium and fluid restrictions, weigh child daily, monitor urine output, monitor neuro status
-If renal involvement increases, dialysis may be indicated.

Question 18

Pharyngitis

Answer 18

-Inflammation of the throat mucosa
-If accompanied with nasal symptoms, often viral. A bacterial sore throat often occurs without nasal symptoms (usually Group A streptococci).
-Complications: peritonsillar or retropharyngeal abscess (may progress to airway obstruction), acute rheumatic fever, acute glomerulonephritis
-Viral: typically self-limiting
-Bacterial: antibiotics (rapid strep test to confirm)
-signs and symptoms: fever, sore throat, difficulty swallowing, headache, abdominal pain
-Inspect pharynx and tonsils for swelling, redness, exudate, petechiae, strawberry tongue
-Administer Tylenol and ibuprofen for pain, throat lozenges, cool mist humidity
-Encourage popsicles, cool liquids, and ice chips to maintain hydration
-May return to school 24 hours after initial dose of antibiotics

Question 19

Croup

Answer 19

-Laryngotracheobronchitis - inflammation of larynx, trachea, and bronchi
-Often caused by Parainfluenza
-Inflammation and edema obstruct the airway, causing an audible inspiratory stridor and a barking cough
-Symptoms occur most often at night, persist suddenly, and resolve in the morning
-Self-limiting , lasting about 3-5 days
-Complications: worsening respiratory distress, hypoxia, or bacterial superinfection
-Usually managed at home but may need to be treated outpatient with corticosteroids, racemic epi and several hours of observation
-Hospitalization required if there is significant stridor at rest or severe retractions after periods of observation

Question 20

Epiglottitis

Answer 20

Inflammation and swelling of the epiglottitis (often caused by H. Flu type B)
-Medical emergency: respiratory arrest and death can occur if airway becomes occluded
-Management: airway maintenance, IV antibiotic therapy, managed in ICU
-signs and symptoms: sudden onset of fever, toxic appearance, refuses to speak or speaks softly, sitting forward with neck extended, drooling, anxious
-Do NOT attempt to visualize throat, it may cause a spasm and occlude airway
-Dysphagia, drooling, anxiety, irritability, and significant respiratory distress : prevent for sudden airway occlusion
-Do not leave child unattended, keep the child and parents as calm as possible, do not allow child to lay supine
-In cases of complete airway occlusion, an emergency tracheostomy may be necessary. May sure all equipment and personnel are prepared and notified.

Question 21

Bronchiolitis

Answer 21

-Acute inflammatory process of the bronchioles and small bronchi
-Usually caused by viral agents (RSV #1, adenovirus, parainfluenza, and HMV also common)
-Peaks in winter and spring, primarily affecting infants and toddlers (after toddlerhood, RSV typically localizes to the UR tract)
-Management is supportive! Supplemental O2, suctioning, oral or IV hydration, bronchodilator therapy
-Hospitalization required for an infant with tachypnea, significant retractions, poor oral intake, or lethargy due to the possibility of needing mechanical ventilation
-Diagnosis: pulse ox, chest x-ray (hyperinflation, atelectasis, infiltration), blood gases showing CO2 retention, PCR
-Teach parents signs of worsening
-Educate families who are high risk: child under 1, born premature, have chronic lung and heart conditions
-Administer Synagis to @ risk infants (premature, CLD, congenital heart disease, certain neuromuscular disorders)

Question 22

Asthma

Answer 22

-Chronic inflammatory airway disorder characterized by airway hyperresponsiveness, airway edema, and mucus production
-Long periods of control with infrequent acute exacerbations OR persistent daily symptoms
-Goal: avoid asthma triggers and reduce or control inflammatory episodes
-Short-acting bronchodilators to treat bronchoconstriction, long-acting forms prevent bronchospasm
-Symptoms: cough (particularly at night), shortness of breath, chest tightness, dyspnea, wheezing
-Labs: pulse oximetry, chest x-ray (reveals hyperinflations), blood gases, pulmonary function tests, peak expiratory flow rate, allergy testing
-Management: clear airway and optimize oxygenation and ventilation
-Educate families on use of nebulizers, meter-dose inhalers, spacers, dry-powder inhalers, medications and side effects of medications

Question 23

Cystic Fibrosis

Answer 23

-Autosomal recessive disorder
-A deletion occurring on the long arm of chromosome 7 at the cystic fibrosis transmembrane conductance regulator (CFTR) is the responsible gene mutation.
-Impacts mucosal surfaces resulting in dysfunction of exocrine glands, causing thickened tenacious secretions in sweat glands, GI tract, pancreas, and respiratory tract
-Sweat glands produce a larger amount of chloride, leading to salty taste of the skin and alterations in electrolyte balance and dehydration.
-Complications: hemoptysis, pneumothorax, bacterial colonization, cor pulmonale, volvulus, intussusception, intestinal obstruction, rectal prolapse, GERD, diabetes, portal hypertension, liver failure, gallstones, and decreased fertility
-Impacts the respiratory system and GI tract
-Respiratory: airway obstruction, respiratory distress, chronic cough, barrel-shaped chest, clubbing, PNA
-GI: meconium ileus, retention of fecal matter, sludging of intestinal contents, obstructive cirrhosis, gallstones, FFT
-Pancreatic enzyme activity is lost, causing malabsorption of fats, proteins, and carbs… poor growth and large malodorous stools.
-Secondary infection due to Staphylococcus aureus, Pseudomonas aeruginosa, and Burkholderia cepacia often occurs.
-Goals: minimize pulmonary complications, maximize lung function, prevent infection and facilitate growth
-Management: CPT, physical exercise, recombinant human Dnase, bronchodilators, anti-inflammatory agents, antibiotics, pancreatic enzymes, vitamins, high calorie/high protein diets
-Labs: Sweat chloride test, pulse oximetry, chest x-ray (hyperinflation, wall thickening, atelectasis, infiltration), PFTs
-Consider impact on patient and family

Question 24

Cardiac Arrhythmias and Arrest

Answer 24

-In children, often caused by gradual deterioration of respiration and/or circulation
-Nurses should know how to manage respiratory alterations and shock in children.
-Bradyarrhythmias: brief drops in HR associated with vagal stimulation are common and should resolved with or without stimulation…however, persistent bradycardia is commonly caused by respiratory compromise, hypoxia, and shock
-Determine underlying cause
-Oxygenation and ventilation, epinephrine or atropine
-Tachyarrhythmias: hypoxia and hypovolemia are pathologic reasons for sinus tachycardia… SVT and ventricular tachycardia are associated with cardiac compromise
-Determine if the child is stable or unstable
-Uncompensated SVT or symptomatic VT requires emergent intervention
-Pulseless rhythms: no palpable pulses or signs of perfusion
-Support ABCs, provide oxygen, give fluids, medications, defib/syn cardioversion
-Key areas to inquire about: hx of cardiac problems/asthma/chromosomal anomaly/delayed growth, symptoms such a syncope/dizziness/palpitations/chest pain/increased WOB, activity tolerance, precipitating illness, participation in sports, family history (sudden death, cardiac conditions)

Question 25

Submersion Injury

Answer 25

-3rd leading cause of preventable death in children
-Survival and neurologic outcome depends on early and appropriate resuscitation
-Aspiration leads to poor oxygenation and retention of carbon dioxide.
-Alveolar surfactant is depleted, commonly leading to pulmonary edema.
-Ask: Where did it occur? (ocean, lake, pool, bath) Fresh or salty? Cold or warm? Length of submersion? Witnesses? Consciousness? When did the child last eat?
-Auscultate for pulmonary edema (coarseness or crackles), neurologic status, temperature (hypothermia often occurs)
-Potentially devastating effects related to hypoxia… airway interventions should be initiated immediately
-Suction, intubation, NG/OG to decompress stomach, warming if hypothermic
-Chest compressions if pulseless

Question 26

Poisoning

Answer 26

-Inquire about time of poisoning and nature of the toxin
-Ingested, inhaled, applied to skin?
-Nausea, vomiting, anorexia, abdominal pain, neurologic changes? Progression of symptoms?
-Inquire about depressed or threatened suicide
-Assess for hyper/hypotension, hyper/hypothermia, respiratory depression or hyperventilation, pupillary contraction or pupillary dilation, mental status, skin moisture and color, bowel sounds
-Chemistry panel, EKG, liver function test, urine and blood tox, specific drug levels
-Prioritize ABCs, treat alterations, monitor vital signs, provide supportive care
-Activated charcoal may be administered to bind with chemicals in the bowel
-Occasionally, dialysis will be required to lower toxin levels in the bloodstream.
-Once toxin is identified, medication to reverse effects may be given… (naloxone for opiate ingestion)

Question 27

Trauma

Answer 27

-Leading cause of death in children is unintentional injuries
-Automobile accidents, pedestrian accidents, sporting and bicycling firearm use
-Young children are not developmentally equipped to recognize dangerous situations.
-Think! Was the child restrained? How fast was the car going? Was a helmet worn? Estimated blood loss? How high did they fall from? What was the surface they landed on?
-Keep in mind the possibility of child abuse.
-ABCs, assess for disability, neurologic function (may range from completely normal to comatose), expose the body to assess for injuries
-Type and cross match, clotting dysfunction, amylase and lipase, liver function, pregnancy test, CT, ultrasound, MRI
-Cervical spine stabilization
-More likely to require blood products due to loss from injury

Question 28

What is Intussusception?

Answer 28

occurs when a proximal segment of the bowel “telescopes” into a more distal segment, causing edema, vascular compromise, and partial or total bowel obstruction