Peds/OB Class 2 Flashcards
When does the foramen ovale close? What causes it to close?
1-2 hours after birth.
It closes because the L Atrium’s pressure becomes higher than the R Atrium’s pressure (once the lungs empty of fluid and resistance in the pulm artery decreases).
When does the ductus arteriosus close? What causes it to close?
About 72h after birth (3ish days)
Closes d/t drop in prostaglandin and the increase in O2 levels in blood.
How do kids differ from adults in cardiac anatomy?
In infants, heart is larger, comparatively.
SBP increases rapidly in 1st 6 weeks, then slowly until adolescence.
Neonates must increase HR to meet CO needs (cannot increase stroke volume)
What will happen to a neonate that cannot increase its HR?
If it’s low enough, it’ll go into CHF
What is clubbing associated with?
Long-term hypoxia, often from CHF
Why would you worry about an eating baby if they were diaphoretic?
Indicates increased work of breathing and O2 demand - sign of CHF.
What are you looking for in an abdominal exam of a child you suspect has CHF?
Palpable liver (or spleen)
How does the body compensate for CHF in kids? What s/s do we see?
Compensates by increasing sympathetic activity. *Tachycardia one of first signs. Cool extremities (shunting to trunk) Retractions, flaring nares, dyspnea Sweaty head when eating Decreased urine output Periorbital edema *decreased play/activity/sports/interest in world! (Activity intolerance) Palpable liver (back pressure
When would you see decreased BP in CHF?
Not until it’s very, very advanced.
How can you best manage CHF (nursing care)?
Keep kids calm Cluster care and allow for scheduled periods of rest Position in semi-Fowler’s Monitor I/Os Encourage one-on-one time Minimize infection risk
What are the goals of CHF treatment in kids?
Improve cardiac function
Remove accumulated fluids (Decreasing cardiac demands)
Improve tissue oxygenation
Provide sufficient nutrition to meet caloric demands
What medication is used for CHF in children - what does it do? What do you need to do before administering it?
Digoxin - increases contractility of the heart
Take apical pulse for one minute
What are the s/s of digoxin toxicity?
Anorexia
Nausea/Vomiting
Bradycardia
Arrythmias
How will you increase caloric intake in babies? Older kids?
-Fortified formula, add fat
-Pump and use bottle if baby isn’t gaining well
Maybe feeding tube at night to supplement
When older, add fat to everything.
What conditions increase pulmonary blood flow?
PDA, ASD, VSD
What conditions obstruct cardiac outflow to body?
CoA, Aortic Stenosis
What conditions obstruct cardiac outflow to lungs?
Pulmonary stenosis, Tetralogy of Fallot
What is a PDA and what causes it? How is it treated?
Patent Ductus Arteriosus (doesn’t close)
Blood moves from aorta back to pulm artery… causing the lungs to get extra blood flow.
Caused by prematurity, higher prostaglandin levels that prevent PDA from closing.
Can give IV PGE inhibitor (Indomethacin). If doesn’t work, will fix after a year old.
What are the s/sx of a PDA?
Harsh, loud murmur that continues through systole/diastole.
(Best heard in armpit)
Tachypnea & resp distress
What is an ASD? What do you see? How/when will it be fixed?
Atrial Septal Defect: hole btw atria that causes blood to flow from left to right.
Results in decreased output to body, and can back up to liver on the R side (s/s of R-sided CHF).
S/Sx Activity intolerance, murmur or extra sounds
If it doesn’t self-repair, surgery at 3-4y/o.
How does the relationship between cyanosis and crying tell you if the problem is pulmonary or cardiac?
Cyanosis that worsens when crying is d/t heart problems because it increases pulmonary resistance.
Cyanosis that improves with crying is pulmonary b/c the deep breathing and air flow improves the condition
What is a VSD? When would you see it? What would you see?
Ventricular Septal Defect.
Hole between the ventricles means that blood pumps from the left ventricle to the R ventricle on contraction. Not as much gets out to the systemic circulation - it keeps circulating through heart and lungs.
Might not see until 1-2m old: takes time for pressures to change in ventricles.
You’d see poor weight gain (small babies, poor feeding)
Fast Heart Rate
Sweaty
S/s of CHF (liver, spleen, heart enlargement)
How (and when) is a VSD treated?
Surgery before 1 year old to prevent hypertrophy
Digoxin, high calorie diet and low stimulation until then.
What is a CoA? When does it start? What will you see?
Coarctation of the Aorta
Aorta narrows at the juncture of the DA (scar tissue) and prevents free passage of blood to the lower part of the body.
Subtle differences start at day 3-4: bluish legs, decreased diapers, increased respiratory rate.
Big sign is the difference in BP between arms and legs.
If older kids have this, you might see headaches d/t high pressure in aortic arch.
If a CoA is noticed early, what treatment will be given?
Prostaglandins: will keep the DA open.
Eventually, will need surgical treatment.
What is aortic stenosis? When do you see the s/s and what are thy?
A narrowing of the aortic valve (obstructs outflow to the whole body).
You’ll see problems as the DA starts to close (3-4d):
- diminished carotid pulses
- low BP
- poor feeding
- Activity intolerance
- older kids might have angina-like CP.
What is pulmonary stenosis? What does it look like?
Narrowing of the pulmonic valve (bringing blood from the right ventricle to the lungs).
Causes R ventricular hypertrophy.
This child will look BLUE.
(Class notes: want the foramen ovale to stay open to keep blood mixing)
What are the four issues in Tetralogy of Fallot?
Combination of VSD
Pulmonary stenosis
Overriding aorta (on top of the VSD)
R ventricular hypertrophy
How does the blood flow in tetralogy of Fallot?
Because of the pulmonary stenosis, the pressure of the blood in the R ventricle overrides that of the left ventricle, and deoxygenated blood goes to the L ventricle. Blood has difficulty getting through lungs, and blood that does oxygenate mixes with deoxygenated blood before going out to body.
What will you see in someone with tetralogy of Fallot?
Cyanosis
Dyspnea
Child might have knees to chest/squatting.
What is TGA? What is the treatment and when?
Transposition of the Great Arteries.
Two non-communicating systems - oxygenated blood never circulates to body.
Need to keep the foramen ovale and DA open.
Surgery by day 2.
What to know about kids and shunts?
You will hear a murmur (if not, something’s wrong)
Blood flow is turbulent - they’re probably on ASA/anticoagulants (be alert for internal bleeding!)
What is Kawasaki’s disease? What are the diagnostic signs/symptoms?
Systemic microvasculitis
Comes on quickly
5 days of 39+ fever and: Bilateral conjunctivitis w/ no discharge Red tongue, mucosal fissures and dryness Swollen hands (edema), peeling of palms/feet Rash on trunk of body Swelling of cervical lymph nodes
What are the s/sx of Kawasaki’s in the acute phase?
Sudden onset fever not responsive to antipyretics/antibiotics
Irritability or inconsolably Redness of mouth HF s/s intermittently Transient arthritis of joints Lymph node swelling at neck
What is the big risk with Kawasaki disease? What do we do to prevent it?
Aneurysm in coronary arteries.
Keep child calm, have mom and dad do all care.
Decrease inflammation
What is the medication treatment for Kawasaki’s disease?
IVIG (IV immune gamma globulin)
High dose aspirin therapy
What are signs of aspirin toxicity?
Ringing in ears, H/A, dizziness, confusion
Bruising easily
What are the s/s of an MI in kids?
Belly pain, vomiting, restlessness, inconsolability, crying, pallor
What is Rheumatic Fever?
Systemic inflammation that happens after a group A strep infection. Autoimmune response.
Heart, joints, CNS, skin, subcutaneous tissues.
What is the treatment for Rheumatic Fever?
Bed rest
Antibiotics
Anti-inflammatants.
What disease other than strep throat can also lead to Rheumatic Fever?
Scarlet Fever, Impetigo
Casts in the urine indicate…
Kidney issues
Nitrites and WBCs in the urine indicate…
Infection
At what age (and what criteria) can ‘nocturnal enuresis’ become a diagnosis?
Older than 5
Twice/week for 3+ months
Main problem
When are enuresis alarms a good fix for nighttime enuresis? What if they don’t work?
When a child is neurologically ready (older than 5).
If they don’t work, desmopressin is a last-line option.
What is vesico-ureteral reflux? What’s the risk?
When urine flows up the ureters when the bladder contracts.
The big risk is infection and renal scarring.
What is the treatment for vesicoureteral reflux?
Prophylactic antibiotics (if kids already have renal scarring or are young)
Correct any voiding dysfunction (and make sure they’re not constipated).
Scheduled voiding
When would you get a CBC on a child?
If there were systemic signs of infection (fever, irritability)
When do you do a VCUG?
Voiding cystourethrogam is done to diagnose vesicoureteral reflux, only after a child has had a UTI.
Age-dependent (if baby, yes. If girl who just learned to potty-train, probably a hygiene problem).
What is CVA tenderness?
Flank pain - fist to kidney area will cause tenderness.
What are s/s of pyelonephritis?
High fever Vomiting AB pain Dehydration CVA tenderness
What is acute post-infectious glomerulonephritis? S/Sx?
Inflammation of the glomeruli after a group A strep infection.
Clogged glomeruli = inflammation, poor filtering, endothelial cell retraction, protein and blood in the urine, sodium/waste retention.
Abrupt anorexia (often brings parents to dr) Oliguria Tea-colored urine HIGH BLOOD PRESSURE Periorbital edema
Would you need a straight cath for a urine sample for APIGN?
Nope - you can pee in a hat. Looking for protein, blood in urine, red/white casts.
What is the treatment for APIGN?
Antibiotics
BED REST (there is a high stroke risk b/c of high BP)
Strict I/Os.
Diuretics, fluid/salt restrictions, BP meds.
What is Nephrotic Syndrome? S/sx?
Unknown cause - kidneys lose a TON of protein in the urine.
BP is NORMAL Pee is frothy Decreased urine output EDEMA EVERYWHERE Low protein in blood hyperlipidemia Immunity gets altered Pale and irritable.
What is the treatment for nephrotic syndrome?
Corticosteroids.
Maybe abx.
Watch I/Os, weight, electrolytes, proteinuria
Check urine in the morning
Don’t eat too many proteins
Skin care - prone to breakdown b/c of puffy-ness.
What is Hemolytic Uremic Syndrome? S/sx?
Caused by toxins released by bacterial breakdown, usually E.coli. Break down blood cells and cause micro clots in vascular places. Triad of problems:
Acute Renal Failure (clog up the kidneys)
Hemolytic Anemia
Thrombocytopenia (petechiae, Purpura)
Looks like stomach flu: ab pain, vomiting, bloody diarrhea 1-2 wk beforehand. Results in bruising, pallor, dark urine (old blood), decreased appetite, irritability.
What should you make sure to check in a pt with HUS (hemolytic uremic syndrome)?
Obv I/Os, but don’t forget effects on brain, lungs and pancreas:
Check Neuro, Breathing, Blood Glucose, too.
What s/sx are you likely to find in a kid with type I diabetes?
Weight loss along with polyuria and polydipsia (sometimes polyphagia).
Dehydration (tachycardia, decreased skin turgor, dry mucosa)
What will electrolyte levels look like in a kid who is going into DKA? How often will you take them?
High CBG
Decreased K+
Decreased HCO3
Increased Ketones
Take them every two hours or more.
How fast do you rehydrate a dehydrated child in DKA? Why? With what?
Slowly, with NS. Cerebral edema if CBG comes down too quickly.
(Check neuro and potassium frequently).
Infant Diabetes considerations?
Tricky to dose d/t rapid growth
CBG 4x/day
If sick, CBG Q4h or even q1h.
Call PCP if ketones in urine or CBG over 250.
Toddlers - Diabetes considerations?
Picky eaters Sick often Check CBG before meals and at bedtime Make rituals. Allow choice. Use words like “prick” or “poke” instead of “shot”
Preschool - diabetes considerations?
Therapeutic play
Let them help, gather supplies
Let them choose from healthy snacks on their own
Control is tricky b/c frequent illnesses
School-age diabetes considerations
Increase carbs with increased activity Learn to check own CBG School issues with teachers Teach them s/s of hypoglycemia and hyperglycemia! 504 plans
Considerations for adolescents with diabetes
Peer-group membership is important
Might be in denial about future impacts of illness
Not great with self-management
Must talk about alcohol and blood sugar
What is the name for velvety, hyperpigmented skin back, neck, armpits, back of knees? What is it associated with?
Acanthosis nigrans
Assoc w/ Type 2 DM
