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Essentials of Acute Care > You can do this! > Flashcards

You can do this! Flashcards

1
Q

Most common organisms associated with viral gastroenteritis

A 
Rotavirus
Adenovirus
Astrovirus
Calicivirus
Coronavirus
Sapovirus
Parvovirus
Top 3-4 are going to be
Rotavirus
Adenovirus
Noravirus
Coronavirus
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2
Q

Organisms associated with bacterial gastroenteritis

A 
Staphylococcus
E.Coli
Campyobacter
Salmonella
Shigella
Yersinia
Vibrio Parahaemolyticus
Aeromonas
Bacillus Cereus
Clostridium Perfringens
C.Difficile
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3
Q

Protozoa and parasites associated with gastroenteritis that cause infection resulting in fluid loss and malabsorption

A

Cryptosporidium
Isospora
Cyclospora

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4
Q

Protozoa and parasites associated with gastroenteritis that directly infect the small bowel leading to malabsorption

A

Giardia

Enteromonas hominis

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5
Q

most common 3 symptoms for gastroenteritis

A

fever
vomiting
diarrhea

not all 3 are required to be present

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6
Q

diarrhea definitions

A

1) a normal BM that has increased in frequency and large water content
2) Stool output greater than 3 times per day (24 hours)

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7
Q

days to be acute diarrhea

A

<= 14 days

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8
Q

days to be persistent diarrhea

A

15-29 days

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9
Q

days to be chronic diarrhea

A

> =30 days

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10
Q

bloody diarrhea, vomiting, and periorbital edema or edema of extremities
should make you think about

A

HUS (Hemolytic Uremic syndrome)

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11
Q

Can ear infections be a reason for vomiting and/or diarrhea

A

yes

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12
Q

diarrhea, vomiting and oral lesions may be a sign of

A

IBD

certain viral illnesses

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13
Q

diarrhea, vomiting, fever, and erythema in the oropharynx or malodorous breath may be evidence of

A

sinusitis or pharyngitis

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14
Q

Pain in the RLQ should make you think

A

appendicitis

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15
Q

Pain in the LUQ may be associated with what organs

A

pancreas

Spleen

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16
Q

Pain at the costovertebral angle may indicate

A

kidney infection

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17
Q

Pain at the flank may be related to

A

pylonephritis

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18
Q

localized pain is a red flag that says what about gastroenteritis

A

that there is another cause for the pain other than gastroenteritis

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19
Q

maintenance ORS guidelines

A

Use for maintenance fluids
<10kg- 60mL-120mL for each episode of vomiting or diarrhea
>10kg - 120-240mL for each episode of vomiting or diarrhea
plus regular diet

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20
Q

ORS for mild to moderate dehydration

severe requires IV fluid

A

first replace fluid deficits then maintain
50-100mL/kg over 2-4 hours

An additional
<10kg- 60mL-120mL for each episode of vomiting or diarrhea
>10kg - 120-240mL for each episode of vomiting or diarrhea

start small (5-10 mL) every 5-10 min and increase as tolerated

after replace losses and vomiting stops, resume diet and continue maintenance ORS

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21
Q

Probiotic use in gastroentritis

A

may shorten by 1 day

Lactobacillus rhamnosus GG (LGG) was most effective

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22
Q

Zinc in gastroenteritis

A

Not formally recommended by CDC but research shows potential reduction in diarrhea with improved outcomes

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23
Q

which organisms cultured from stool would a pt need to demonstrate several negative stool cultures before returning to school or daycare

A

Salmonella serotype Typhi
Shiga toxin-producing E.Coli (STEC)
E.Coli 0157:H7
Shigella

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24
Q 
In general, other than 
Salmonella serotype Typhi
Shiga toxin-producing E.Coli (STEC) 
E.Coli 0157:H7
Shigella

afebrile pts with gastroenteritis may return to school when?

A

when they have less than 3 episodes of loose stool a day

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25
Q

Which organism does the book point out as the cause for nearly 600,000 visits to HCPs , upwards of 70,000 hospitalizations and 20-70 deaths exceeding 1 billion in care costs

A

Rotavirus

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26
Q

Type of transmission for Gastroenteritis

A

Fecal-oral transmission

person to person…direct…fomites, ect

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27
Q

a right lower quadrant pain elicited by pressure applied on the left lower quadrant

A

Rovsing’s sign

appendicitis

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28
Q

Rovsing’s sign

A

a right lower quadrant pain elicited by pressure applied on the left lower quadrant
appendicitis

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29
Q

the point on the lower right quadrant of the abdomen at which tenderness is maximal

A

McBurney’s point

appendicitis

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30
Q

McBurney’s point

A

the point on the lower right quadrant of the abdomen at which tenderness is maximal
appendicitis

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31
Q

Pain is elicited by having the patient lie on his or her left side while the right thigh is flexed backward

A

Psoas sign

appendicitis

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32
Q

Psoas sign

A

Pain is elicited by having the patient lie on his or her left side while the right thigh is flexed backward
appendicitis

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33
Q

discomfort felt by the subject/patient on the slow internal movement of the hip joint, while the right knee is flexed with lateral movement of flexed knee outward

A

Obturator sign

appendicitis

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34
Q

Obturator sign

A

discomfort felt by the subject/patient on the slow internal movement of the hip joint, while the right knee is flexed with lateral movement of flexed knee outward

appendicitis

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35
Q

What sign?

pain with coughing

A

Dunphy

appendicitis

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36
Q

Dunphy sign

A

pain with coughing

appendicitis

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37
Q

What sign

pain with heel drop

A

Markle sign

appendicitis

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38
Q

Markle sign

A

pain with heel drop

appendicitis

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39
Q

stool that has the appearance and consistency of liquid tar, is black in color and offensive in odor

A

Melena

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40
Q

The vast majority of patients with UGI bleeding have ________ or _____ secondary to _____

A

lesions of the GI mucosa
esophageal varices
liver disease

The vast majority of patients with UGI bleeding have lesions of the GI mucosa or esophageal varices secondary to liver disease

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41
Q

most common cause of colonic bleeding worldwide

A

Infectious colitis

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42
Q

an infant with GI bleeding who is fed cows milk or soy based formula may have

A

allergic collitis

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43
Q

A history of dry heaves followed by hematemesis or melena may suggest

A

Mallory Weiss tear

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44
Q

Recent illness with GI bleeding may lead you to what

A

HUS

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45
Q

Ingestion of ______ can lead to gastritis, duodenitis, or ileal and right colonic lesions

A

NSAIDS

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46
Q

Liver disease may be related to what inherited deficiency

A

Alpha 1 antitrypsin

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47
Q

what disease can be transmitted at birth and affect the liver

A

Hepatitis B

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48
Q

BRUE symptom with GI bleed…think…

A

UGI bleed such as esophagitis, gastritis or ulcer

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49
Q

Urgency to defecate or Tenesmus ( the feeling that you need to pass stools, even though your bowels are already empty) suggests

A

colitis

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50
Q

Delayed passage of meconium or constipation in infancy can be a sign of

A

Hirschsprung disease

Cystic Fibrosis

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51
Q

The presence of spider angiomata, palmar erythema, fetor hepaticus or splenomegaly suggests chronic ______ disease and _____ _____

A

Chronic liver disease

Portal Hypertension

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52
Q

If a pt is on antibiotics and getting no enteral nutrition, what should you be concerned with?

A

Killing the intestinal track’s vitamin K producing bacteria which will cause the patient’s prothrombin time (PT) to rise, resulting in a coagulopathy. Add NG suction to this perfect storm and you have an UGI bleed from the NG tube suction induced mucosal injury

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53
Q

GI bleed patient that you find a palpable moveable rectal mass on might identify _____ as a possible etiology

A

Polyps

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54
Q

what are some things that patients may ingest that can give the appearance of blood in stool

A

commercial dyes (#2 and #3)
Blueberries
Beets
Bismuth

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55
Q

what diagnostic exam is used if you suspect upper GI bleeding

A

upper endoscopy

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56
Q

what diagnostic exam is used if you suspect bright red lower GI bleeding

A

Colonoscopy

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57
Q

what organism is associated with bleeding duodenal or gastric ulcer

A

Helicobacter Pylori

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58
Q

What should occur with bleeding esophageal varices or varices that have recently bled

A

Should be sclerosed or banded to decrease risk of re-bleeding

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59
Q

what medication is used to decrease central venous pressure for management of bleeding esophageal varices before endoscopic intervention

A

Octreotide

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60
Q

In the case of variceal bleeding that is not controlled by endoscopic and/or tamponade intervention, what procedure is warranted

A

emergency transjugular intrahepatic portosystemic shunting (TIPS) or surgical shunting to decrease portal hypertension may be warranted

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61
Q

In patients with significant GI bleeding who the source was not detected by upper endoscopy and colonoscopy, what is next step

A

a nuclear medicine tagged RBC bleeding study to help find source of blood loss

(bleeding will have to be brisk enough to detect with this scan)

If actively bleeding, an angiogram with selective vessel embolization may be required

A single or double balloon enteroscopy may help identify a radiographically silent lesion or one beyond the reach of the conventional upper or lower endoscope

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62
Q

does a negative gastric lavage test with NGT rule out UGI bleed

A

No, bleeding may have stopped or pylorospasm could be preventing blood from a duodenal source from entering the stomach

Not routinely performed for a stable patient with formed brown guiac positive stools

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63
Q

why is continuous suction via NGT controversial in GI bleeds

A

can exacerbate bleeding

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64
Q

Polyps are removed with what during a colonoscopy

A

Electrocautery

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65
Q

When does GI bleeding resolve in Henoch-Schonlein Purpura (HSP) and HUS

A

with resolution of the disorders

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66
Q

UGI bleeds - when can the patient resume their diet

A

within 24 hours

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67
Q

Upper GI bleed discharge meds

A

PPI for gastritis
Beta blocker (propanolol) for esophageal varices
follow up with GI

lower GI bleeds will depend on the etiology of the bleed

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68
Q

upper GI bleeding differentials
infant vs young child vs older child/adolescent

Bolick chart pg 441

A

All ages

  • Hemorrhagic gastritis/gastritis
  • Stress ulcer
  • Reflux esophagitis

Infant only
-Vascular malformation

Young child to adolescent

  • gastric/duodenal ulcer
  • Esophageal varices
  • Epistaxis
  • Mallory-Weiss tear

Young Child

  • Foreign Body
  • Toxic Ingestion
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69
Q

Lower GI bleeding differentials
infant vs young child vs older child/adolescent

Bolick chart pg 441

A

All ages

  • Infectious colitis
  • Anal fissures

Infant only

  • Necrotizing enterocolitis
  • Milk Protein Allergy
  • Hirschsprung disease
  • Lymphonodular hyperplasia

Infant and young child

  • Midgut volvulus
  • Intussusception

young child only

  • Pseudomembranous colitis
  • Ischemic colitis

young child through adolescence

  • Hemorrhoid
  • Ulcers
  • Polyps
  • Juvenile Polyps
  • Hemolytic-uremic syndrome (HUS)
  • Inflammatory bowel disease
  • Henoch-Schonlein purpura (HSP)
  • Meckel Diverticulum
  • Angiodysplasia
  • Graft-vs-host disease

older child through adolescence
-Bacterial enteritis

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70
Q

Pediatric end-stage liver disease scoring formula

A

PELD score = 1 x (0.48 x (bilirubin)) + (1.857 x (INR)) - (0.687 x (albumin)) + listing age factor + growth

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71
Q

Upper GI bleed vs Lower GI bleed is differentiated by the

A

Ligament of Treitz (located between jejunum and duodenum)

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72
Q

hematemesis is associated with upper or lower GI bleeding

A

upper

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73
Q

Hematochezia is associated with upper or lower GI bleeding

A

Lower

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74
Q

Most common intra- abdominal tumors in children

A

neuroblastoma and Wilms tumor

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75
Q

an ischemic and inflammatory disorder of the bowel most prominently seen in the jejunum, ileum, and colon primarily affecting premature infants after then initiation of enteral feeding.

A

Necrotizing enterocolitis (NEC)

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76
Q

What happens in NEC

A

intestinal injury then activates the gut’s inflammatory cascade, causing mucosal damage and allowing invasion of the bowel wall by bacteria

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77
Q

who is at highest risk for NEC

A

preterm infants in the first 6 weeks of life
more than 90% of cases occur in preterm infants born less than 32 weeks PCA and birth weights less than 1500gms

10% of NEC cases occur in term infants with underlying pre-existing illnesses such as congenital heart disease

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78
Q

Maternal risk factors associated with NEC

A

placental insufficiency
gestational hypertension with superimposed pre-eclampsia
maternal smoking
maternal infection/inflammatory conditions

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79
Q

shiga-toxin producing organism strain that causes gastroenteritis

A

E. coli O157:H7

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1222). Wolters Kluwer Health. Kindle Edition.

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80
Q

what organism for bacterial gastroenteritis is antibiotics contraindicated in treating

A

E. coli O157:H7

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81
Q

antidiarrheal medications for gastroenteritis for kids

A

Antidiarrheal medications often contain aspirin, which contributes to Reye syndrome and should be avoided.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1223). Wolters Kluwer Health. Kindle Edition.

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82
Q

causes of inflammatory bowel disease

A

Crohn disease

ulcerative colitis.

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83
Q

Meckel diverticulum (ectopic gastric mucosa) is most common in what age

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1224). Wolters Kluwer Health. Kindle Edition.

A

school aged children

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84
Q

coffee ground emesis….are you thinking upper or lower GI bleed

A

upper

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85
Q

Management of GI bleed, unstable

A
  • Obtain IV access and administer fluid volume.
  • Initial fluids: normal saline, lactated Ringer solution, and/or packed RBCs (PRBCs).
  • NPO.
  • Proton pump inhibitor; intravenously.
  • Consider octreotide for bleeding esophageal varices; may also require banding via upper endoscopy.
  • Consider vitamin K administration if coagulopathy noted.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1225-1226). Wolters Kluwer Health. Kindle Edition.

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86
Q

infant risk factors for NEC

A 
gestational age
birth weight less than 1500 gms
nonhuman milk enteral feeding
circulatory instability with associated GI ischemia
Anemia with blood transfusion
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87
Q

clinical presentation of NEC

A 
mild to gaseous abd distention
feeding residuals - can be bilious or bloody
vomiting
bloody stools
signs of shock
also can have
lethargy
episodes of apnea
resp distress
bradycardia
desaturations
temp instability
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88
Q

diagnostic for NEC

A

AP or Lat decub of abdomen may show ileus, dilated loops of bowel, pneumatosis intestinalis, ascites, intrahepatic portal venous air, persistent fixed loops of bowel and free air indicative of perforation

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89
Q

lab findings commonly found in NEC

A 
metabolic acidosis
thrombocytopenia
neutropenia
coagulopathies
electrolyte disturbances
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90
Q

Management of NEC

A 
decompression of bowel
broad spectrum abx coverage for sepsis
supportive care
NPO
collect blood cultures, urine, CSF
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91
Q

pneumatosis intestinalis on x ray

A

NEC

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92
Q

The infant with medical NEC will typically recover after

A

prolonged period of bowel rest (parenteral nutrition support)
empiric treatment for infection (7-10 days)

if they perforate they will need peritoneal drain or laparotomy of diseased segments of bowel

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93
Q

abd mass with weight loss, anorexia, fever, night sweats, and often easy bleeding or bruising

A

think neoplasm

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94
Q

abd mass with hx of bilious emesis or encopresis (fecal incontinence)

A

bowel obstruction

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95
Q

cola- colored urine and acholic stools

A

Urinary excretion of bile salts

associated with renal pathology of abd mass

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96
Q

RUQ masses most often involve

A

liver
gallbladder
biliary tree

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97
Q

Epigastric masses can include both

A

epigastric hernias

Diastasis recti

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98
Q

LUQ masses think

A

spleen
stomach
adrenal gland
kidney

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99
Q

R and LLQ masses may be from

A

ovarian and fallopian processes

or intestines in orgin

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100
Q

suprapubic masses are most commonly ____ in nature

A

genitourinary

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101
Q

mobility or immobility of abd mass suggest

A

degree of attachment or invasion of the retroperitoneum

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102
Q

immobile abd mass

A

invasive tumors or

masses that arise from the retroperitoneal organs

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103
Q

Tenderness to abd mass generally suggests

A

a recent change such as bleeding

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104
Q

Firmness, hardness and irregularity of an abd mass suggest either

A

tumor or

desmoplasia (scar)

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105
Q

smoothness of an abd mass suggests

A

encapsulated mass

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106
Q

Tympany indicates

A

gas such as in a hollow viscus

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107
Q

dullness indicates

A

fluid or solid mass

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108
Q

diagnostic imaging for Hepatobiliary and pancreatic masses

A 
Neither US nor CT is effective at imagining the biliary and pancreatic ductal system 
HIDA scan (Hepatobiliary iminodiacetic acid)- traditionally used first now have MRCP (magnetic resonance cholangiopancreatography is now used for hepatobiliary and pancreatic disease
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109
Q

milk allergy typically presents how long after introduction of dairy into diet

A

within a week

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110
Q

types of benign cystic lesions (uncommon in children)- abd masses

A

choledochal cyst
polycystic kidney disease
duplication cyst
cystic teratoma

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111
Q

most common age of presentation of a neuroblastoma

A

18 months with the prevalence greatest in children <4 yrs

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112
Q

Most common renal tumor and 5th most common pediatric malignancy

A

Wilms tumor

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113
Q

Most common age of presentation of Wilms tumor

A

1-5 yrs

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114
Q

most common malignant liver tumor

A

Hepatoblastoma

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115
Q

mean age at diagnosis for hepatoblastoma

A

1 year old

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116
Q

What is hepatoblastoma associated with (increased risk factors)

A 
extreme prematurity
very low birth weight
Beckwith-Wiedemann syndrome
Gardner syndrome
Familial Adenomatous Polyposis Disease
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117
Q

what is the preferred diagnostic test for neuroblastoma

A

CT

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118
Q

what race and gender is at highest risk for NEC

A

Black males

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119
Q

prevention for NEC

A

Breastfeeding

preliminary evidence shows probiotics

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120
Q

type of small bowel obstruction….

history of surgery

A

adhesive SBO

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121
Q

type of small bowel obstruction….

with bilious or feculent vomiting and no gas or stool

A

Complete obstruction

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122
Q

type of small bowel obstruction….

decreased stool and almost no gas

A

partial SBO

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123
Q

Bilious vomiting should always suspicious for

A

malrotation with volvulus

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124
Q

why? In pyloric stenosis, their vomitus never contains bile

A

because gastric outlet obstructed proximal to duodenum

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125
Q

Gastric peristaltic waves are often visible in LUQ in

A

pyloric stenosis

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126
Q

“olive” may be palpated

A

pyloric stenosis

Hypertrophied pylorus “olive” may be palpated

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127
Q

lab expectations in pyloric stenosis

A

Hyperchloremic, hypokalemic metabolic alkalosis, elevated BUN secondary to dehydration

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128
Q

xray in pyloric stenosis

A

xray- show huge stomach and diminished or absent gas in intestine

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129
Q

string sign

A

pyloric stenosis

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130
Q

treatment for pyloric stenosis

A

Hydration
electrolyte correction
Surgery - Pyloromyotomy (Ramstedt’s procedure)

Before surgery correct dehydration and hyperchloremic alkalosis
NS bolus followed by infusion of ½ NS containing 5% dextrose and KCl when urine output is observed

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131
Q

classic presentation age for pyloric stenosis

A

3-6 weeks old

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132
Q

Alvardado/MANTRELS rule

A 
Appendicitis
1 point for each the following-
-Migration of pain to RLQ
-Anorexia
-N/V
-Rebound pain
-Temp of at least 37.3
-WBC great then 75% neutrophils
2 points for each of 
-tenderness in RLQ and
-leukocytosis greater than 10,000

Children with score of 4 or less- unlikely appy
Score of 7 or greater- increased likelihood

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133
Q

thick-walled appendix with surrounding fluid

Diameter over ___mm considered dx

A

6

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134
Q

most common reason for abd surgery in kids in the US

A

appendicitis

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135
Q

most common age and gender for appendicitis

A

Although it can occur at any age, it is most commonly diagnosed between 10 and 12 years of age and occurs more often in males than females.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1200). Wolters Kluwer Health. Kindle Edition.

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136
Q

a finger-like structure projecting from the cecum,

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1200). Wolters Kluwer Health. Kindle Edition.

A

Appendix

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137
Q

perforated appendicitis treatment

A

• Antibiotic therapy is generally prescribed for 5 to 7 days depending on patient response. Ceftriaxone and Flagyl for perforated appendix have proven to be adequate.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1204). Wolters Kluwer Health. Kindle Edition.

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138
Q

Characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, renal injury

A

HUS

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139
Q

Most common type of HUS

A

prodromal diarrheal illness (D+HUS)
Contaminated meat, fruit, veggie, or water with verotoxin producing E.coli (O157:H7) or Shigella → will have hemorrhagic enterocolitis and progress to HUS

140
Q 
what am I?
presents without prodrome of diarrhea
Can occur at any age 
More severe
Can be secondary to infection (strep pneumo, HIV), genetic, medication, malignancy, SLE, pregnancy
A

Atypical HUS

141
Q

Entercolitis with bloody stools, followed in 7-10days by weakness, lethargy, anuria/oliguria
Irritable, pallow, petechiae
Dehydration, however some children have volume overload (hypertension may occur)
CNS seizures in 25%, pancreatitis, cardiac dysfunction, colonic perforation

A

D+ HUS

142
Q

Lab smear: microangiopathic hemolysis
Anemia, thrombocytopenia, schistocytes/helmet/burr cells on smear, incr LDH, incr indirect bili, incr AST, incr reticulocyte
Coombs test is NEGATIVE
Renal injury: elevated Cr, hematuria, proteinuria, pyuria, casts on UA
Leukocytosis, E coli stool culture, shiga toxin, elevated amylase/lipase

A

HUS

143
Q

Treatment of HUS

A

Volume repletion
Hypertension control
Managing renal insufficiency – dialysis
RBC transfusions
DO NOT GIVE PLATELETS – may add to thrombotic microangiopathy
Only give if active hemorrhage or procedural
NO ABX OR ANTIDIARRHEAL – will make HUS worse

144
Q

double bubble sign on x ray

A

volvulus

145
Q

coffee bean sign on x ray

A

volvulus

146
Q

swirl sign on CT

A

volvulus - diagnostic

147
Q

an infant with acidosis and abdominal distension is most suspicious for

A

bowel obstruction

148
Q

infant with aganglionic section of bowel

A

Hirschsprung’s disease

149
Q

absence or obstruction (due to fibrosis) of the biliary tree, (extrahepatic) leading to intrahepatic bile duct obstruction and proliferation.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1207). Wolters Kluwer Health. Kindle Edition.

A

Biliary atresia

150
Q

types of Biliary atresia

A

(1) syndromic BA and associated malformations (i.e., BA splenic malformation syndrome, cat-eye) and random malformations (e.g., esophageal atresia (EA), jejunal atresia, malrotation)
(2) cystic BA—cystic change in an obliterated biliary tract
(3) cytomegalovirus-associated BA, in which the infants have positive serology
(4) isolated BA (largest group of infants).

•Proposed nongenetic etiologies: infection, intrauterine infection, toxin exposure.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1207). Wolters Kluwer Health. Kindle Edition.

151
Q

physical exam findings in biliary atresia

A

jaundice
acholic stools
dark urine

labs
hyperbili
elevated LFT

152
Q

infectious causes of biliary atresia

A 
viral hepatitis
TORCH
Toxoplasmosis
other agents
Rubella
Cytomegalovirus
Herpes simplex
153
Q

diagnostics for biliary atresia

A

• Radiologic evaluation. • Abdominal ultrasound: gallbladder noted to be absent or small. • Hepatobiliary scintigraphy, in which there is no excretion of the isotope detected in the intestine. • Confirmatory cholangiogram is done at the time of laparotomy/laparoscopy for surgical intervention.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1208). Wolters Kluwer Health. Kindle Edition.

154
Q

surgical management for biliary atresia

A

• Kasai procedure or portoenterostomy. • Best results in children <2 months of age in experienced hands. •Excision of the extrahepatic biliary tract and anastomosis of a Roux-en-Y limb to the jejunal limb at the porta hepatis. •The goal of the procedure is to reestablish bile flow as evident by pigmented stool in the immediate postoperative period. •Deemed a successful operation if conjugated bilirubin level is <2 mg/dL at 3 months postop; long-term outcome is variable with a small percentage of children achieving lasting drainage that is effective. • Complications: bacterial cholangitis.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1208). Wolters Kluwer Health. Kindle Edition.

155
Q

mutation in CFC1 gene

A

biliary atresia

156
Q

most common indication for liver transplant

A

biliary atresia

157
Q

biliary atresia nutritional requirements

A
  • Nutrition. • Require 130% to 150% of the recommended daily allowance, and many require 150 kcal/kg/day to achieve appropriate growth. • May require formulas with increased medium chain triglycerides as they do not require bile acids for digestion (e.g., breastmilk, Pregestimil, or Portagen). • Supplement with fat-soluble vitamins (A, D, E, and K).
  • Supplemental nocturnal feeds with a nasogastric (NG) tube may be necessary for growth failure.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1208-1209). Wolters Kluwer Health. Kindle Edition.

158
Q

Acute cholecystitis is often attributed to the presence of

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1210). Wolters Kluwer Health. Kindle Edition.

A

Gallstones

159
Q

Hypoalbuminemia and abdominal mass may suggest

A

nonspecific but indicates significant illness

160
Q

Uric acid and LDH plus abdominal mass may indicate

A

Solid tumors

161
Q

Abdominal mass plus BUN and Creatinine may indicate

A

Renal dx

162
Q

Abdominal mass plus elevated amylase and lipase levels may indicate

A

pancreatic dx

163
Q

Abdominal mass plus elevated LFTs think

A

Liver dx

164
Q

2 view abd x ray with abdominal mass will show things such as

A

Intestinal obstruction
fecal impaction
calcifications associated with tumor

165
Q

US in the setting of abdominal mass may be used to

A

identify origin of the mass
solid vs cystic
can help further lab testing and imaging

166
Q

CT scan with IV contrast in the setting of abdominal mass may be used to

A
  • evaluate solid abd mass
  • vascular abnormalities
  • associated lymph nodes
  • stage many types of cancers
  • helps with cystic mass to see if there is continuity with bowel or bladder
  • Not helpful if mass of primary bowel or bladder -> Fluoroscopic studies such as UGI series, BE and voiding cystourethrogram
  • Oral contrast will cause artifact to the bowel and bladder
167
Q

best diagnostic exam for abdominal mass of primary bowel or bladder

A

Fluoroscopic studies such as UGI series, BE and voiding

168
Q

what diagnostic is used for hepatobiliary and pancreatic masses?

A
  • Neither US nor CT is effective at imagining the biliary and pancreatic ductal system
  • HIDA scan (Hepatobiliary iminodiacetic acid)- traditionally used first now have MRCP (magnetic resonance cholangiopancreatography is now used for hepatobiliary and pancreatic disease
169
Q

radiograph after standing for 2 minutes has maximum sensitivity for free gas suggesting perforation. (Bowel perforation)

A

Abdominal X-ray- upright chest radiograph

170
Q

radiograph that has better sensitivity than other radiograph views because gas collects around the liver. Looking for bowel perforation

A

Left lateral decubitus

171
Q

Radiograph useful for proximal bowel obstruction

A

Upper GI contrast series

172
Q

imaging Usually appropriate if the abdominal radiograph or physical examination suggests distal bowel obstruction (as might be seen in Hirschsprung disease).

A

contrast enema

173
Q

imaging used to determine bowel obstruction site

A

CT with IV contrast. Do not use contrast if suspect perforation

174
Q

on imaging you see numerous air fluid levels, distended bowel normally more central
what does this sound like

A

small bowel obstruction

175
Q

on imaging you see few to no air fluid levels. Distended bowel normally more peripheral

A

Large bowel obstruction

176
Q

what type of obstruction?

a small bowel obstruction in a patient who has had surgery or a severe infection of the abdominal cavity

A

Adhesive bowel obstruction

177
Q

what type of bowel obstruction?

there will be bilious and feculent vomiting with no gas or stool passage per anus

A

Complete bowel obstruction

178
Q

what type of bowel obstruction??

decreased stool passage and almost no gas passage

A

Partial bowel obstruction

179
Q

causes of functional bowel obstruction

A 
Abd surgery
Peritonitis
Sepsis
Trauma
Medications (opioids, anxiolytics)
Metabolic imbalances (hypokalemia, hyponatremia, hypomagnesemia, acidosis)
180
Q

causes of mechanical bowel obstruction

A 
Postoperative adhesions
Hematoma
Intussusception
Distal intestinal obstruction syndrome
Malrotation with volvulus
Tumors
Bezoar
Congenital abnormalities:
-Duodenal atresia
-Duodenal web
-Annular pancreas
-Jejunoileal atresia
181
Q

an obstruction caused by a loop in the intestines that twists around itself and surrounding mesentery

A

Volvulus

182
Q

volvulus that happens in the last part of the large intestines leading to the rectum

A

Sigmoid volvulus

183
Q

volvulus that happens in the beginning part of the large intestines

A

cecal volvulus

184
Q

volvulus that happens in the small intestines

A

midgut volvulus

185
Q

which type of volvulus is the most common type?

A

sigmoid volvulus

186
Q

occurs when small bowel twists around the superior mesenteric artery, resulting in vascular compromise to large portions of the midgut.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1242). Wolters Kluwer Health. Kindle Edition.

A

Volvulus

187
Q

______volvulus may lead to widespread intestinal ischemia and progress rapidly to necrosis of the bowel, perforation, shock respiratory failure, and death.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1242). Wolters Kluwer Health. Kindle Edition.

A

Midgut

188
Q

At approximately the _____week of embryonic life, the gut begins to change from a straight-line structure to an elongated tube herniating into the umbilical cord.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1242). Wolters Kluwer Health. Kindle Edition.

A

4th

189
Q

Abdominal rotation and attachments are complete by __ months’ gestation.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1243). Wolters Kluwer Health. Kindle Edition.

A

3

190
Q

______ occurs when the bowel fails to rotate after it returns to the abdominal cavity.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1243). Wolters Kluwer Health. Kindle Edition.

A

Malrotation

191
Q

Presentation of malrotation is usually when and how does it appear?

Presentation of 
infants
older infants
children
adolescents

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1243). Wolters Kluwer Health. Kindle Edition.

A

in the first year of life with symptoms of acute or chronic bowel obstruction.

Infants present within the first week of life with bilious emesis and acute bowel obstruction.

Older infants present with episodes of recurrent colicky abdominal pain.

Children may present with recurrent episodes of vomiting, abdominal pain, or both.

•Occasionally, patients may present with malabsorption or protein-losing enteropathy associated with bacterial overgrowth. Symptoms are caused by intermittent volvulus or duodenal compression by Ladd bands or other adhesive bands affecting the small and large bowel.

25-50% of adolescents with malrotation are asymptomatic

Symptomatic adolescents present with acute intestinal obstruction of history of recurrent episodes of abdominal pain with less frequent vomiting and diarrhea.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1243). Wolters Kluwer Health. Kindle Edition.

192
Q

If you suspect malrotation what labs are you ordering?

what is diagnostic?

A

CBC
type and screen
electrolytes (imbalances secondary to vomiting and 3rd spacing fluid into the bowel and abd cavity)

anemia can be caused by pooling of blood intestines

-Flat and upright or lat decub abd x rays - evaluates for intestinal obstruction but cannot diagnose malrotation

Upper GI Series is the preferred study to evaluate the position of the ligament of Trietz
•If malrotation exists, UGI will show abnormal position of the ligament of Trietz, partial obstruction of the duodenum, with a spiral or corkscrew appearance, and proximal jejunum in the right abdomen.
•When volvulus is present, the barium column is noted to end in a peculiar beaking effect and pathognomonic for a volvulus.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1244). Wolters Kluwer Health. Kindle Edition.

193
Q

management of Malrotation with volvulus

A

emergent LADD procedure

194
Q

Preop management for Malrotation with volvulus

A

cardiopulmonary and circulatory resuscitation. A gastric decompression tube should be placed, along with the administration of broad-spectrum antibiotics, to cover gut flora.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1244-1245). Wolters Kluwer Health. Kindle Edition.

195
Q

bilious vomiting in a neonate is highly suspicious for

A

malrotation with volvulus until proven otherwise

196
Q

cecal volvulus usually occurs in what age group

A

young adults

197
Q

______ volvulus is most commonly seen in babies and small children

A

midgut volvulus

198
Q

coffee bean sign on x ray

A

volvulus

199
Q

birds beak shape on barium enema

A

volvulus

200
Q

sigmoid volvulus is usually treated with

A

sigmoidoscopy

201
Q

A _______ may be used to resolve a cecal volvulus

A

Colonoscopy

202
Q

A colonoscopy cannot be used to treat a _____ volvulus

A

midgut

203
Q

The most common presenting symptom in Chrohn’s disease

A

is abdominal pain. Pain is commonly crampy, epigastric or periumbilical, and intermittent

204
Q

increases the risk of IBD

A

smoking
oral contraception
infectious colitis
infectious agents

205
Q

treatment of Chrohn’s disease

A

Aminosalicylates; oral or IV steroids are more important in reducing remission.

206
Q

is an umbrella term for Crohn disease and ulcerative colitis, which are inflammatory processes of the GI tract with very similar presentations.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.

A

Inflammatory Bowel Disease

207
Q

•The difference between Crohn disease and Ulcerative Colitis is

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.

A

based on the location and characteristics of the inflammation.

208
Q

inflammatory process that can affect any portion of the GI tract. Most commonly affects the terminal ileum. The inflammation is in the entire lumen of the intestines.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.

A

•Crohn Disease:

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.

209
Q

inflammatory process that affects the colon and rectum. The inflammation is in the mucosal layer of the intestinal wall.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.

A

Ulcerative colitis:

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.

210
Q

Inflammatory bowel disease is most commonly diagnosed between ____ and ____ age with a second peak between 50-80 yrs of age

A

15 and 30

genetic predisposition that is turned on by environmental factors that causes an excessive immune response that results in chronic intestinal inflammation.

211
Q

pain, diarrhea, weight loss, perirectal inflammation with fistula.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1236). Wolters Kluwer Health. Kindle Edition.

A

Crohn disease

212
Q

bloody, watery diarrhea, weight loss, tenesmus, and urgency.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1236). Wolters Kluwer Health. Kindle Edition.

A

Ulcerative colitis

213
Q

gold standard diagnosis of IBD

A

Endoscopy of the intestinal tract with biopsy and histology

214
Q

Labs in IBD workup

A 
CBC
ESR
CRP
LFT
GGT
IBD serology
Stool studies looking for infectious etiology of diarrhea
215
Q

induction of remission in IBD

A
  • Corticosteroids are used as first-line therapy for induction and remission after an IBD flare-up. During induction of remission, all maintenance medications are continued because they have the ability to induce remission or help the action of the corticosteroids.
  • Exclusive PN for 8 weeks with bowel rest. This therapy has a similar remission rate as corticosteroids with less side effects.
  • Biologic agents (e.g., Infliximab) are used for severe inflammation or refractory to other treatments to help induce remission.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1236-1237). Wolters Kluwer Health. Kindle Edition.

216
Q

Maintenance of remission in IBD

A

• Immunosuppressive medications are used to maintain remission because of slow onset of action. • Aminosalicylates (5-ASA) reduce inflammation to maintain remission in mild UC and Crohn disease. • Immunosuppressive therapy should be started while still on steroid treatments; steroids are then tapered. • Supplementary nutrition with any treatment. Probiotics are useful as adjunct therapy. • Antibiotics have a role in treating perirectal fistula or abscess in Crohn disease. •Surgical intervention is appropriate for patients with refractory disease, uncontrolled GI bleeding, bowel perforation, or stricture causing an obstruction, with bowel resection being the last option. •Total colectomy in UC with J-pouch is the surgical treatment of refractory disease, toxic megacolon, perforation, or severe colitis. In UC, a total colectomy can be curative. •Resection of a stricture or area of colitis in Crohn disease is the surgical treatment. In severe cases when the intestines become perforated, an ostomy is required.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1237). Wolters Kluwer Health. Kindle Edition.

217
Q

Ulcerative colitis is most commonly seen in what age group

A

20-30 yrs old

218
Q

Ulcerative colitis symptoms

A

Systemic:

  • Fatigue
  • Fever
  • Weight Loss
  • Dyspnea
  • Palpitations (iron def anemia secondary to blood loss)

GI

  • Bloody Diarrhea
  • Colicky Abd pain
  • Tenesmus

Extraintestinal

  • Arthritis
  • Uveitis
  • Episcleritis
  • Skin Lesions (pyoderma gangrenosum & erythema nodosum)
  • Primary sclerosing cholangitis
  • Venous/Arterial Thromboemboli
219
Q

Acute complications of UC

A 
Severe GI bleeding
Fulminant colitis (bleeding with more than 10 stools per day)
Toxic megacolon (nerves and muscles damaged with the colon atonic and dilated) -> can lead to perforation with peritonitis (fevers and severe abd pain)
220
Q

Long term complications of UC

A
  • increased risk for colorectal cancer

- strictures ->rectosigmoid colon which can lead to bowel obstruction

221
Q

Chrohns disease symptoms

A

Systemic

  • Fatigue
  • Fever
  • Weight loss

Gastrointestinal

  • Crampy abd pain
  • Watery diarrhea
  • Malabsorption symptoms (Steatorrhea)
  • Fistulas (Communication between 2 epithelial organs)
  • Phlegmon -> abscess
  • oral (ulcers, gingivitis)
  • Gallstones (biliary colic

Extraintestinal

  • Arthritis
  • Uveitis
  • Episcleritis
  • Skin Lesions (pyoderma gangrenosum & erythema nodosum)
  • Primary sclerosing cholangitis
  • Venous/Arterial Thromboemboli
  • Kidney stones
222
Q

string sign

A

strictures

can be seen in Crohns disease

223
Q

skip lesions

A

Chrohns disease

not seen in UC

224
Q

IBD with ileal involvement

A

common in Crohns disease

not seen in UC

225
Q

IBD with fistulas

A

Common in Chrohns disease

very rare in UC

226
Q

smoking decreases risk of

A

UC

increases risk of CD

227
Q

an ilieus is a

A

non-mechanical obstruction of the intestines (caused by a disruption of peristalsis that can be partial or complete resulting in dilation of proximal intestines

228
Q

Most common cause of an ileus is form

A

manipulation of intestines during surgery

229
Q

clinical presentation of ilieus

A

Abd distention
absent/hypoactive bowel sounds
pain
vomiting

230
Q

diagnostic for ileus

A

abd x ray

231
Q

management of ileus

A

Bowel rest
decompression with NG
Adequate postop pain management w/non-narcotic meds
Routine postop care to include ambulation and time

232
Q 
if an infant doesnt pass meconium within first 48 hrs
abd distension
refuses to feed
bilious vomiting
what should be on your differential
A

Imperforate anus
Meconium ileus
Hirschsprung’s disease

233
Q

VACTERL Syndrome

A 
Vertebral defects
Anal atresia
Cardiac anomalies
Tracheoesophageal fistula
Esophageal atresia
renal anomalies
limb anomalies
234
Q

meconium ileus is seen with what disease process

A

Cystic fibrosis

235
Q

what test is for cystic fibrosis if newborn screening test isnt back yet

A

Abnormal sweat chloride test

>60mmol/L

236
Q

on exam the newborn has a empty rectum with no meconium and with normal sphincter tone

A

Meconium ileus which is a surgical emergency

237
Q

Abd x ray
Dilated bowel loops
“Soap Bubble”/”Ground Glass” appearance

A

Meconium ileus

238
Q

Squirt sign or blast sign

A

explosive of gas or liquid stool after digital rectal exam (relieves obstruction temporality) in Hirschsprung’s

239
Q

anorectal maonometry will show failure of anal sphincter to relax

A

Hirschsprung’s

240
Q

Disease is due to injury to the mucosa of the small intestine caused by ingestion of gluten (protein component) from wheat, barley, rye, and related gains (causes flattening of the finger-like villi in the small intestine that are used for absorption)

A

Celiac disease

241
Q

celiac disease is associated with what other diseases and syndromes

A

Type I DM
Thyroiditis
Turner’s syndrome
Trisomy 21

242
Q

Diagnostic for Celiac

A

Biopsy diagnostics: villus atrophy; screening with IgA antitissue transglutaminase and antigliadin; resolution of symptoms with gluten elimination and relapse on oral challenge

243
Q

clinical manifestations of celiac disease

A

Chronic diarrhea, irritability, decreased appetite, malabsorption, abdominal distension, flatulence, FTT, weight loss, ascites caused by hypoproteinemia

Other symptoms can include osteopenia, arthritis or arthralgias, ataxia, dental enamel defects, elevated liver enzymes, dermatitis herpetiformis, and erythema nodosum

244
Q

what should be considered in Should be considered in any child with chronic abdominal complaints, short stature, poor weight gain, or delayed puberty

A

Celiac

245
Q

Serological markers for celiac

A

IgA antiendomysial antibody
IgA tissue transglutaminase antibody (ANTI -tTG)

IgA deficient - Use IgG screening test

246
Q

Biopsy for celiac

A

Small bowel biopsy essential to confirm the diagnosis and should be performed while patient still ingesting gluten
Biopsy shows various degrees or villous atrophy (short or absent villi), mucosal inflammation, crypt hyperplasia, and increased numbers of intraepithelial lymphocytes

247
Q

treatment for celiac

A

Elimination of gluten from diet

248
Q

what skin rash can be seen in celiac

A

Dermatitis herpetiformis

249
Q

Celiac disease increases risk of

A

small bowel cancer
T-cell lymphoma
due to chronic inflammation and immune system activation

250
Q

infection responsible for most ulcers in stomach and duodenum in adults; plays a lesser role in childhood ulcer disease

A

H.Pylori

251
Q

What drugs put you at higher risk for Peptic ulcer disease

A

NSAIDS
Tobacco
Bisphosphonates
Potassium supplements

252
Q

other than meds, what other risk factors for PUD

A 
Family history
sepsis
head trauma
burn injury
hypotension
253
Q

symptoms of peptic ulcer disease

A
  • “Alarm” symptoms (GI bleeding, weight loss, early satiety, dysphagia or odynophagia, family history of upper GI malignancy, iron deficiency anemia or new upper GI symptoms in patients older than 55)
  • Weight loss, hematemesis, melena (heme-positive stools), chronic vomiting, microcytic anemia, nocturnal pain
254
Q

what type of ulcers?

pain occurs several hours after meals and often awakes patient at night; eating tends to relieve the pain

A

Duodenal ulcers

Gastric and duodenal ulcers heal in 4-8 weeks in 80% patients

255
Q

what type of ulcers?
pain aggravated by eating, resulting in weight loss, GI bleeding can occur; symptom relief with antacids or acid blockers

A

Gastric ulcers

Gastric and duodenal ulcers heal in 4-8 weeks in 80% patients

256
Q

diagnostics for Peptic ulcer disease

A

Endoscopy mandatory with alarm symptoms
Test for H. Pylori
CBC, ESR, amylase, lipase, abd US

-“Alarm” symptoms (GI bleeding, weight loss, early satiety, dysphagia or odynophagia, family history of upper GI malignancy, iron deficiency anemia or new upper GI symptoms in patients older than 55)

257
Q

H-Pylori treatment with ulcers. regimen is twice daily for 1-2 weeks

A
  • Omeprazole (Prilosec)-clarithromycin-metronidazole (flagyl)
  • Omeprazole- amoxicillin- clarithromycin
  • Omeprazole-amoxicillin-metronidazole
  • Other Proton pump inhibitors (PPI) may be substituted when necessary and bismuth compounds may also be considered
  • Tetracycline useful in adults but should be avoided in children less than 8 yo
258
Q

Treatment for PUD with no H. Pylori

A

PPI

259
Q

syndrome that causes a tumor leading to duodenal ulcers

A

Zollinger-Ellison syndrome

260
Q

Risk factors for GERD

A

neurologic impairment, obesity, repaired EA or other congenital esophageal disease, cystic fibrosis, hiatal hernia, repaired achalasia, family history of gastroesophageal reflux disease (GERD).

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1218). Wolters Kluwer Health. Kindle Edition.

261
Q

the symptoms or complications of gastroesophageal reflux.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1218). Wolters Kluwer Health. Kindle Edition.

A

GERD

Gastroesophageal reflux: the movement of gastric contents into the esophagus.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1218). Wolters Kluwer Health. Kindle Edition.

262
Q

irritants of peptic ulcers

A

NSAIDS
Alcohol
Tobacco
Caffeine

263
Q

Primary cause is transient relaxation of the lower esophageal sphincter, which allows gastric contents to move into the esophagus.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1218). Wolters Kluwer Health. Kindle Edition.

A

Gastroesophageal reflux

GERD

264
Q

clinical presentation of GERD

A 
•   Poor weight gain, feeding aversion. 
•   Unexplained crying, choking, or coughing.
 •   Sleep disturbances.
 •   Gagging. 
•   Regurgitating. 
  Dental erosion (older child).
-Dystonic head positioning (Sandifer syndrome)
-Abdominal or chest pain (older child)

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1219). Wolters Kluwer Health. Kindle Edition.

265
Q

GERD infant managment (non-pharmacologic)

A

• Elevate head of crib 30°; can use reflux wedge, avoidance of overfeeding, upright position for 30 minutes after feeding. • Consider a 1-to-2 week trial of hypoallergenic formula. • Increase caloric density of formula, or consider tube feeding if poor weight gain.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1219-1220). Wolters Kluwer Health. Kindle Edition.

266
Q

GERD child or adolescent non pharmacologic managemment

A
  • Elevated head of bed, left-sided positioning, avoidance of caffeine, chocolate, fatty or spicy foods, carbonated beverages.
  • Small frequent meals, avoid eating 2 to 3 hours before bedtime. • Lose weight if overweight.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1220). Wolters Kluwer Health. Kindle Edition.

267
Q

medication management for GERD

A

• H2 blockers are generally first-line choice, especially for infants. • Proton pump inhibitors; not indicated for infants <1 year of age. • Prokinetic agents can be used to promote stomach emptying.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1220). Wolters Kluwer Health. Kindle Edition.

268
Q

surgical management for GERD

A

•Nissen fundoplication—the fundus of the stomach is wrapped around the lower esophagus to improve function of the lower esophageal sphincter. • Complication rates are higher in neurologically impaired children. •Due to the risk of complications, usually reserved for those children with multiple pneumonia episodes felt to be related to aspiration and those with intractable reflux unresponsive to medical therapy.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1220). Wolters Kluwer Health. Kindle Edition.

269
Q

one of the most common causes of vomiting in infant

A

pyloric stenosis

270
Q

Vomiting secondary to gastric outlet obstruction from hypertrophied pyloric muscle and subsequent gastric outlet obstruction.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1252). Wolters Kluwer Health. Kindle Edition.

A

Pyloric stenosis

271
Q

onset of symptoms age for pyloric stenosis

A

2-8 weeks of age with peak at 3-5 weeks

272
Q

common findings on chemistry in pyloric stenosis

A

Hypochloremia
hypokalemia
hyperbilirubinemia

273
Q

•Peristaltic waves may be visualized across the abdomen. •Olive-sized mass may be palpated in right upper quadrant.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1253). Wolters Kluwer Health. Kindle Edition.

A

Pyloric stenosis

274
Q

diagnostic confirmed for Pyloric stenosis with

A

abdominal US

275
Q

How do we fix pyloric stenosis

A

Pyloromyotomy either open or laparoscopically - splits the pyloric muscle to increase diameter and gastric emptying

276
Q

After a pyloromyotomy, when can feedings restart

A

once gastric contents are able to empty into duodenum, usually 6 hours postop

277
Q

Telescoping of segment of proximal bowel into downstool bowel, usually occur between 1-2 yrs old

A

Intussusception

278
Q

symptoms of Intussusception

A

Sudden onset of crampy abdominal pain- infants knees draw up and infant cries out and exhibits pallor with colicky pattern occurring every 15-20 minutes
Feedings are refused
As it progresses and becomes prolonged- bilious vomiting and dilated fatigued intestine generate less pressure and less pain
Currant jelly stools
Lethargy – glassy eyes and groggy infant
Sausage shaped mass palpable in RUQ or epigastrium

279
Q

imaging for Intussusception

A

Abdominal US
Pneumatic or contrast enema under fluoroscopy – can be used to identify and treat intussusception
Air and barium

280
Q

most common cause of intestinal obstruction in infants and children. It can lead to intestinal death and high morbidity if untreated.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1237). Wolters Kluwer Health. Kindle Edition.

A

Intussusception

281
Q

who is Intussusception most commonly seen in

A

slight increase among white males

282
Q

idiopathic Intussusception is most common in what age group

A

infants and young children

283
Q

idiopathic Intussusception - association with what?

A

recent URI or gastroenteritis

284
Q

Lead point intussusception is most common in what age

A

5-14 years

285
Q

Lead point intussusception - increased risk with what

A 
Meckel diverticulum
Polyps
cyst
carcinoid tumors
foreign bodies
hemangioma
Non-hodgkins lymphoma
Intestinal hematomas
Henoch-schonlein purpura
286
Q

Postsurgical intussusception is typically seen after

A

abd or chest surgery from decreased motility after anesthesia

287
Q

in babies what is the leading edge most often from that causes intussusception

A

Lymphoid hyperplasia (enlargement of lymph tissue such as peyers patches)

288
Q

sausage like mass in abdomen

A

intussusception

289
Q

intussusception can lead to what complication

A

obstruction and even volvulus

290
Q

Bull’s eye sign

A

intussusception

291
Q

a congenital defect in which there is interruption of the continuity of the esophagus; the esophagus ends in a blind pouch;

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1213). Wolters Kluwer Health. Kindle Edition.

A

Esophageal atresia

292
Q

Esophageal atresia

Type A is

A

EA without fistula

293
Q

Esophageal atresia

Type B is

A

EA with proximal fistula

294
Q

Esophageal atresia

Type C is

A

EA with distal fistula; most common type

295
Q

Esophageal atresia

Type D is

A

EA with proximal and distal fistulas

296
Q

Esophageal atresia

Type E is

A

Tracheoesophageal fistula without atresia

297
Q

•Newborn with excessive oral secretions, drooling, accompanied by coughing, choking, or sneezing. • Feeding can cause cyanosis, choking, and emesis.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1214). Wolters Kluwer Health. Kindle Edition.

A

Esophageal atresia

298
Q

diagnostic for Esophageal atresia

A

•Failure to pass NG or orogastric tube into the stomach. •Chest radiograph—anteroposterior and lateral, which demonstrates NG tube coiled in upper esophagus. •Assess for VACTERAL (Vertebral, Anorectal, Cardiac, Tracheoesophageal, Renal, and Limb anomalies) association.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1214). Wolters Kluwer Health. Kindle Edition.

299
Q

Most pt with an esophageal atresia have a

A

Tracheoesophageal fistula

300
Q

In Esophageal atresia The end of the oral gastric tube is typically observed at the ___ to ____ level

A

T2 to T4

301
Q

when air is seen in the stomach and bowel with a esophageal atresia, the presence of what is confirmed

A

distal fistula

However a gasless abdomen on CXR does not negate the presence of a fistula. The TEF can be proximal

302
Q

​​Holiday-Segar Method:

A

1-10 kg= 100 mL/kg/day
10-20 kg= add 1,000 mL + 50 mL/kg/day for every kg greater than 10
> 20 kg= 1,500 mL + 20 mL/kg/day for every kg greater than 20

303
Q

421 method

A

4 mL/kg/hr for 1st 10 kg
Example: a 10kg pt would receive 40 mL/hr
2 mL/kg/hr for next 10 kg
Example: a 20kg pt would receive 60 mL/hr
1 mL/kg/hr thereafter
Example: a 30kg pt would receive 70 mL/hr

304
Q

BSA method

A

Used for pts who are 10 kg or over

1600 mL/m2/day

305
Q

which maintenance fluid calculation method is the most accurate

A

BSA

306
Q

standard formula or breastmilk has how many kcal/oz

A

20 kcal/oz

307
Q

Fortified formula/EBM has how many kcal/oz

A

22-30 kcal/oz

308
Q

Pediasure has how many kcal/oz

A

30kcal/oz

309
Q

If you have 20kcal in 1 oz

how many kcal in 1 mL

A

20 divided by 30

= 0.66Kcal/mL

310
Q

most common type of dehydration, often related to gastroenteritis where losses of water and salt in stool are typically balanced

A

isonatremic

311
Q

type of dehydration?

If patient also has vomiting and more loss of water than salt occurs (most dangerous d/t neurologic damage)

A

Hypernatremic

312
Q

type of dehydration?

Results from loss of fluid, especially salt, in stool or sweat

A

Hyponatremic

313
Q

tachycardia is present in what degree of dehydration

A

moderate and severe

314
Q

Palpable pulses are decreased in what degree of dehydration

A

severe

weak pulses in moderate

315
Q

Orthostatic hypotension is seen in what degree of dehydration

A

moderate

316
Q

Hypotension is seen in what degree of dehydration

A

severe

317
Q

absent tears are seen in what degree of dehydration

A

severe

318
Q

in Hyperchloremic dehydration what is the preferred fluid replacement

A

LR

319
Q

advantage of LR over NS

A

NS will make you more acidotic. pH of NS is 5.7, pH of LR is 6.75

320
Q

what increases insensible losses

A 
Fever (12.5% per degree >38 C)
heat
sweating
tachypnea/hyperventilation
vomiting/diarrhea
Hyperosmolar states (dehydration and DKA)
321
Q

what decreases insensible losses

A

Renal failure
Humidity
Hypothermia
Hypometabolic states

322
Q

Standard of care of care for diagnosis of pyloric stenosis and intussusception

A

US

323
Q

Reserved for either treatment or diagnostic uncertainty when US cannot diagnose pyloric stenosis or intussusception

A

Fluoroscopy

324
Q

Excellent for imaging the biliary tree, gallstone dx

A

MRI

325
Q

Diagnosing appendicitis

A

CT

326
Q

diagnosing pancreatitis

A

Acute is a result of inflammation from injury/insult. Diagnosed by having at least 2 of the 3 symptoms=
Abdominal pain (or surrogate symptoms such as irritability or listlessness)
Elevation of serum pancreatic enzymes
Radiological findings

327
Q

what diagnostic test?
•Used to assess colon for etiology of obstruction, some problems include intestinal atresia and Hirschsprung disease.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1255). Wolters Kluwer Health. Kindle Edition.

A

Air or barium enema

328
Q

a plain frontal supine radiograph of the abdomen that visualizes from the diaphragm to the bladder. A KUB will aid in observation of calcifications, gas patterns, feces, or free peritoneal air.

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1257). Wolters Kluwer Health. Kindle Edition.

A

KUB

329
Q

•Useful study in detecting GI conditions as well as assessment of indwelling devices (e.g., NG tubes, jejunal tubes).

Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1257-1258). Wolters Kluwer Health. Kindle Edition.

A

KUB

330
Q

where is olive shaped mass found in pyloric stenosis

A

epigastric

331
Q

Amylase levels are ____ for first 2 months of life

A

low

332
Q

Children up to age ___ have virtually no pancreatic amylase

A

2

333
Q

Adult amylase levels may not be reached until

A

later school-age or adolescent years

334
Q

Kidney insufficiency may lead to hyper/hypo amylasemia

A

hyperamylasemia

335
Q

what labs are elevated in pancreatitis

A

amylase
lipase

other labs affected:
hypocalcemia, transient hypoglycemia, hyperbilirubinemia (d/t possible obstruction of pancreatic duct), increased LFTs, and hypoalbuminemia may be found in conjunction with pancreatitis.

336
Q

imaging of choice for pancreatitis

A

US

337
Q

imaging for chronic pancreatitis

A

ERCP- invasive; sedation is required
Used for chronic pancreatitis to visualize anatomy, perform manometry of sphincter of Oddi, perform therapeutic maneuvers when indicated
Should be avoided during an acute attack of pancreatitis

338
Q

Na level

A

135-145

339
Q

sodium is key in what body functions

A

key to skeletal muscle function, nerve, and myocardial action potentials

340
Q

causes of hyponatremia

A

Hypervolemia -> renal failure, nephrotic syndrome, CHF, and water intox

Hypovolemic - renal losses, diuretic use, diarrhea, vomiting, burns

Normovolemic -> CNS diseases like cerebral salt wasting or meningitis

341
Q

Presentation of hyponatremia

A

nausea, lethargy, seizures, coma

342
Q

Treatment goals for raising sodium in hyponatremia

A

Raise 2-4 mEq/L every 4 hours (10-20 in 24 hours)

If comes in seizing - get to 125 quickly with HTS (3%)
Formula - 0.6x (wt in kg) x (target Na - measured Na)

343
Q

causes of hypernatremia

A
  • Excessive Na intake
  • Inappropriately concentrated formula
  • Excessive free H2O loss→ -breastfeeding failure,
  • –diarrhea,
  • DI
344
Q

presentation of hypernatremia

A

weakness, lethargy, decreased DTR’s, irritability, muscle cramps, renal failure, AMS, seizures

345
Q

diagnostic for hyper/hyponatremia

A

serum Na and osmols

346
Q

treating hypernatremia

A

Avoid decreasing more than 12-15 mEq/L in 24 hours→ risk for cerebral edema

If hypovolemic, calculate free water deficit= 0.6 X kg X (current Na/desired Na) - (0.6 X wt kg)
-This is how much water they’ll need in the next 24 hours. Can give free water PO or via NGT. Be careful if decreasing with IV because D5W will bring level down fast→ check lytes every 2-4 hours. Will typically continue with maintenance of ½ NS or ¼ NS with D5W Y’ed in so that Na level is brought down slower.

Essentials of Acute Care (9 decks)

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