peds exam #2
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what is a Denver II assessment
- The Denver II is a screening test to compare child’s performance on a variety of tasks to other children the same age.
- i. Children age birth to 6 yrs old
- ii. Age is adjusted if premature birth
- iii. Not an IQ test
Denver II sections and tasks
- i. Personal-Social: starts with regarding a face and progresses to things like waving bye-bye, feeding a doll, naming a friend, dressing without help, and finally preparing a bowl of cereal.
- ii. Fine motor-Adaptive: starts with following to midline to things like putting a block in a cup, making a tower of 2,4,6,8 cubes, drawing a person with 3 parts to 6 parts, and finally copying a square.
- iii. Language: starts with responding to a bell to things like being able to say 2,3,6, words, combining words, counting blocks, naming colors, and defining words.
- iv. Gross Motor: starts with equal movements, to lifting the head, sitting without support, standing, walking, kick a ball forward, throw a ball overhand, hopping, and progressively balancing on one foot for 3,4,5,6 seconds.
Denver II post-test
- i. Evaluate child’s behavior during the test
- ii. Typical (yes or no)
- iii. Compliance (always complies, usually complies, rarely complies)
- iv. Interest in surroundings (alert, somewhat disinterested, seriously disinterested)
- v. Fearfulness (none, mild, extreme)
- vi. Attention Span (appropriate, somewhat distractable, very distractable
Denver II score
- i. P for Pass (successfully performs item or caregiver says they can at home),
- ii. F for Fail (cannot do it or caregiver says they cannot do it),
- iii. N.O. for No Opportunity,
- iv. R for Refusal (minimize this reaction by telling child to do it instead of asking them)
Denver II age calculation
Calculating Age todraw age line: subtract child’s DOB from Test Date. When necessary, borrow 12months from a year and 30 days from a month
- Year Month Day
- TD (2012-1yr=2011) (10+12mo=22-1mo=21) (08+30days=31)
- DOB 2006 12 28
- 5yrs 9mo 10 days
Denver II physical assessment
same as an assessmentfor an adult; however caregiver is necessary to give information like medicalhistory and be sensitive when examining gastrointestinal area and asking aboutgenitourinary habits
how to calculate weight using age
age(yrs) x 2 + 8 = weight in kg
calculate b/p using age
- age(yrs) x 2 + 80 = systolic
- 2/3 systolic = diastolic
24hour total body fluid calculation that is dependant on weight in kg
how to calculate maintenance fluid
- 4ml/kg 1-10 = __cc/hour
- 2ml/kg 11-20 = __cc/hour
- 1ml/kg 21+= __cc/hour
anterior fontanel should be checked in what position
- a. lying down
- b. sitting up
- a dose of a substance (as a drug) given intravenously
- A. How much? Depends on weight.
- B. Howfast? As fast as you can under 15 minutes
what is a physical survey?
a head to toe review that should be complete, at minimum, once each shift.
first sign of shock or stress in infant or children
What does a sunken or bulging fontanel indicate?
Sunken fontanel may indicate dehydration whereas bulging fontanelle indicates increased intracranial pressure
What is always a medical emergency in infants
maintaining warmth during observation is always __________for infants
infants are Prone to _________ and __________ as well as _______.
fluid loss, hypothermia, cold stress
Temperature of infants may be taken via the _______or in the ___
axilla , ear
Bowel sounds in infants
Bowel sounds should be active in all four quadrants and the abdomen should not be distended or tender to palpation
Pulse rate gradually _________ with age until regular values are reached.
puse rate average by age group
- newborn - 125
- 1-11 month - 120
- 2yrs - 110
- 4yrs - 100
- 6yrs - 100
- 8yrs - 90
- 10yrs - 90
normal rate of respirations by age group
- birth-1month: 30-40
- 1month-1year: 26-40
- 1-2years: 20-30
- 2-6years: 20-30
- 6-10years: 18-24
- adolescent: 16-24
what are common sites for taking blood pressure on children
- posterior tibial artery
- Oral: 36.4 – 37.4 C / 97.6-99.3 F
- Rectal: 37.0-37.7 C/ 98.6 – 100.0 F
- Axillary: 35.8 – 36.6 C / 96.6 – 98.0 F
- Tympanic: 36.9 – 37.5 C / 98.4 – 99.5 F
1. Normal Structure & function of Respiratory System (Lecture notes)
- Nose, pharynx, larynx, trachea, epiglottis, bronchi, bronchioles and Alveoli exchange carbon dioxide and O2 in the bloodstream
- Air entering body is cleansed, warmed and humidified by respiratory system
Foreign Body Aspiration
- 1-3 years of ageb. Could be anythingc. Not everything will x-rayd. Manifestations
- Respiratory distress without fever
- Spasmodic coughing
- Careful and complete history needed
- bject may drop into main stem bronchi- usually right lung
- Possible scope to see it
- Removal of object if possible
Manifestations and Diagnosis of Tonsillitis & Adenoiditis
- 1. May result from pharyngitis
- 2. Most infections are viral, but some may be caused by GABHS
- 3. Throat culture to diagnosis tonsillitis
- 4. Fever
- 5. Difficulty eating, swallowing or breathing
- 6. May block passage of air through nose- mouth breathingTonsils may have exudate
Treatment and nursing care of Tonsillitis & Adenoiditis
- 1. Analgesics for pain
- 2. Antipyretics for fever
- 3. Antibiotics if bacterial – caused
- 4. Tonsillectomy and Adenoidectomy if:
- a. Chronic (3 per year for 3 years)
- b. Obstructive sleep apnea
- c. Malformation causing speech problems
Pathophysiology Tonsillitis & Adenoiditis
Tonsils and adenoids are located in the pharynx and are made of lymph tissue. The lymph tissue plays a part of the body’s defense mechanism against infection. Enlarged adenoids block the nasal passage, resulting in mouth breathing
Symptoms Tonsillitis & Adenoiditis
- i. Difficulty swallowing and breathing
- ii. Symptoms similar to those of nasopharyngitis
Nursing care for Tonsillitis & Adenoiditis
- i. Providing a cool mist vaporizer to keep the mucous membranes moist
- ii. Salt/water gargles
- iii. Throat lozenges
- iv. Cool liquid diet
- v. Acetaminophen
Tonsillitis & Adenoiditis Treatment
- i. Removal of tonsils and adenoids
- ii. Tonsillectomy is indicated only if persistent airway obstruction or difficulty in breathing
Tonsillitis & Adenoiditis Postoperative care
- i. Watch for increase in pulse rate and respirations, such as an increase in pulse rate and respirations, restlessness, frequent swallowing, or vomiting of bright red blood.
- ii. May use ice collar
- iii. Small amounts of clear liquids are given as tolerated
- iv. If child can handle popsicle they can move to a soft diet
- v. Coughing clearing the throat and blowing the nose are avoided to decrease the risk of precipitating bleeding
- vi. Written instructions are given to the parents
Nasopharyngitis (Common Cold) lecture notes
- 1. Inflammation and infection in nose/throat
- 2. 7200 viruses
- 3. Incubate 1 – days, infectious now
- 4. Last 4 to 10 days
- 5. Droplet precautions
Nasopharyngitis (Common Cold) Clinical Manifestations
- 1. Fever
- 2. Irritability/restlessness
- 3. Sneezing
- 4. Muscle aches
- 5. Cough
- 6. Irritation of nose and throat
- 7. Infants difficulty with nursing
- 8. Possible vomiting/diarrhea
- 9. 6-8 colds per year for children is common
Nasopharyngitis (Common Cold) Diagnosis
- 1. Similar symptoms of other contagious diseases
- a. Measles
- b. Allergic rhinitis
Nasopharyngitis (Common Cold) Treatment
- 1. Sleep and adequate nutrition
- 2. Saline drops in nose
- 3. Bulb syringe
- 4. Decongestant possible for kids > age for
- 5. Humidification
- 6. Increase fluid intake
- 7. AntipyreticsIf symptoms persist, take to PCP to r/o Otitis media
Nasopharyngitis (Common Cold) Pathophysiology
- i. Also know as acute Coryza
- ii. Most common infection of the respiratory tract
- iii. Caused by number of viruses, principally the rhino viruses
- iv. Spread by sneezing, coughing or direct contact
- v. The age, state of nutrition and general health of the child contribute to the susceptibility level
Nasopharyngitis (Common Cold) Manifestations
- i. Child is going to be different than an adult
- ii. Fever as high as 40 C (104 F)
- iii. Nasal discharge
- iv. Irritability
- v. Sore throat vi. Cough
- vii. General discomfort
- viii. Vomiting ix. Diarrhea
Nasopharyngitis (Common Cold) Complications
- i. Bronchitis
- ii. Pneumonitis
- iii. Ear infections
Nasopharyngitis (Common Cold) Treatment and Nursing care
- i. No cure
- ii. Following treatment is designed
- 1. Rest – fatigue should be prevented. Nurse should consider and developmental level of the child
- 2. Clear airways- congested nasal passages caused discomfort and impede nursing or sucking of formula. Fluid consumption is essential to prevent fever and dehydration, the airways must be cleared before feeding or bedtime. Nurse can provide nose drops or suctioning with a bulb syringe
- 3. Adequate fluid intake – Anorexia is common in children with nasopharyngitis. Fluids should be encouraged. Cool, bland liquids are usually tolerated well
- 4. Prevention of fever – Ibuprofen or acetaminophen can be administered when high fever accompanies a cold
- 5. Skin Care – A petroleum based ointment can be applied to the nares and upper lib to prevent skin irritation from a nasal discharge.
what is the triad of diabetes management?
Balanced diet, presise insulin administration, and exersize.
dose diabetes require special foods?
- There is no scientific evidence that persons with diabetes require special foods. – nutritional needs for diabetic children is no different than the nutritional needs nondiabetic needs
what is the goal with nutrition management in children with diabetes?
· The goal of nutrition management in children is are to ensure growth and development, to distribute foods intake so that it aids in metabolic control, and to individualize diet to child’s ethnicity, age, sex weight, activity and family economics, and food preferences
what is the recomended intake for children with diabetes?
Recommended intake is 55% carbohydrate, 30% fat, and 15% protein.
what type of carbohydrates are recomended for children with diabetes?
Carbohydrate intake should be complex carbohydrates, <- they absorb slowly and don’t cause a sudden spike in blood glucose levels.
are sorbitol and xylitol good for children with diabetes
· Sorbitol and xylitol should not be used as artificial sweeteners, because they contribute to diabetic complications.
what type of fat is recomended for children with diabetes?
· Dietary fat from animals should be skipped for plant sources.
are there any supliment recomended for children with diabetes
· Diabetic children may need special supplements to accommodate growth patterns and exercise needs.
should a diabetic trust th e school lunch system?
· Diabetic Children should bring their own lunch to school.
is fiber good for diabeteics?
· Fiber is really important, as are raw fruits, and vegetables
What is Lipotrophy?
· LIPOTROPHY = change that can occur in subcutaneus tissue at the injection site. – teach child to check for lumps.
what is the usual method of insulin dilevery?
· The usual method is subcutaneous. It may be easier for a child to learn to inject at a 90 degree angle because children are less coordinated.
what about injecting insulin after exersixe
· Don’t inject into a site that has a temporarily increased circulation ( like thighs just after running)
Determine the weights of the following kids in kgs
1 year old
5 years old
10 years old
- 1. 1 year old = 10 kg
- 2. 5 year old = 20 kg
- 3. 10 year old = 40 kg
List 3 things that can increase a pediatric patients heart
- 1. Fear
- 2. Pain
- 3. Medication
never wait for ___________________to initiate volume resuscitation
Name 2 places to check for crt (capillary refilltime
Please GCS this scenario
14 year old victim fell from a tree. He is awake, alert, oriented to place, time, and person. He is verbally appropriate but obviously frightened. He moves his upper extremities but is unable ot move his legs
- a. Verbal score
- b. Eye opening score
- c. Motor score
List 3 developmental characteristics of agegroup 12 – 15 years old
- 1. Acne
- 2. Puberty
- 3. Increased awareness of self
List 3 differences between adult and pediatric airways
- 1. Length
- 2. Diameter
- 3. Volume capacity
- 4. More anterior
- 5. Larynx higher
The anterior fontanel should be check in whatposition
A. How much
B. How fast?
- A. ? Depends on weight
- B. As fast as you can under 15 minutes
how do you weigh an infant?
Infant is weight completely naked in a warm room.
What should be put on a scail before you weigh a baby
A fresh absorbent pad or scale paper is placed on the scale. Prevents cross-contamination
in what manner do you weigh an older child?
An older adult is weighed in the same manner as an adult.
how do you test the height of a child
The child’s height is measured along with weight. The infant’s height must be measured while the infant is lying on a flat surface along a metal tape measure or yardstick. Knees should be pressed flat on table. Measurement is taken from top of the head to the heels and recorded
normal structure of the Respiritort system
Nose, pharynx, larynx, trachea, epiglottis, bronchi, bronchioles and lungs
what do alveoli do?
Alveoli exchange carbon dioxide and O2 in the bloodstream
what does the respiratory do toair as it enters?
Air entering body is cleansed, warmed and humidified by respiratory system
what does the respiratoy system do? . BIG
- i. Air enters the body through the nares, or nostrils.
- ii. The mucous membranes and cilia that line the respiratory tract warm, moisten, and filter the air as it passes to the pharynx.
- iii. The pharynx contains the tonsils, which assist in infection control.
- iv. The larynx is at the upper end of the trachea contains the epiglottis, the glottis, and the vocal cords, which prevent food and fluids from entering the trachea and allow voice sounds.
- v. The trachea is encircled by smooth muscle and cartilage to maintain patency and carries the air to the bronchi and then to the smaller bronchioles.
- vi. The bronchioles continue to divide and lead to small, this air sacs (alveoli) that are kept open on inspiration by the air contained in them.
- vii. During expiration when the air sacs collapse, surfactant prevents the walls from sticking together, allowing for re-inflation.
- viii. Gas exchange occurs in the alveoli by diffusion to the bloodstream.
- ix. The volume of air inhaled with each breath is related to body size.
Foreign Body Aspiration
- a. Inhalation of foreign object
- b. 1-3 years of agec. Could be anythingd. Not everything will x-raye. Manifestations
- i. Respiratory distress without fever
- ii. Spasmodic coughing
- iii. Gagging
a. Treatment forigne body Asperation Treartment
- i. Careful and complete history needed
- ii. Object may drop into main stem bronchi- usually right lung
- iii. Possible scope to see it
- iv. Removal of object if possible
What is Allergic rhinitis
a. Is an inflammation of the nasal mucosa caused by an allergic response/sensitization to animal dander, house dust, pollens and molds? It often occurs during specific seasons. It is not a life-threatening condition, does not require hospitalization, but occurs in 10% of children and accounts for many school absences.
1. Allergic rhinitis mast cells
a. The mast cells in the nasal mucosa respond to an antigen by releasing mediators such as histamine. A generalized parasympathetic response can follow.
1. Allergic rhinitis Characteristic signs
a. Characteristic signs: nasal congestion, clear watery discharge, sneezing, itching of the eyes
The allergic salute
- a. The allergic salute: typical rubbing of the nose in response to nasal discharge
- i. darkened circles under the eyes, caused by an obstruction of lymphatic and vein flow
- ii. transverse crease across the bridge of the nose resulting from the allergic solutes
- iii. mouth breathing \
- iv. reddened conjunctiva
allergic Rhnitis Diagnoses
- a. Diagnoses: i. Lab tests of the mucous membranes of the nose reveal the presence of eosinophils and skin sensitization testing may be + for specific allergens.
- ii. history of seasonal occurrence, family history of allergy or asthma iii. appearance iv. absence of fever or purulent drainage
Allergic Rhinitis Treatment
- a. Treatment: i. nonsedating antihistamine and decongestants to reduce edema of the nasal mucous membranes if > 4 yrs old
- ii. Xyzal now approved for kids > 6 months for indoor allergies, > 2 yrs for outdoor allergies
- iii. prophylactic therapy with cromoclyn inhalants or glucocorticoid nasal sprays (if antihistamines are not effective)
- iv. immunotherapy may be prescribed to identify allergens
Allergic Rhinitis: nursing goal
- i. help parent identify the difference between the allergy and a cold, provide a referral for medical care and support
- ii. Teach family about controlling environmental exposure.
- iii. dust control iv. prevention of contact with animal dander
- v. the use of air-conditioners and
- vi. high-efficiency planning of vacation locales that do not present pollen challenge
- vii. leukotriene antagonist drugs have also been effective in treatment
What is Asthma?
a. A syndrome caused by increased responsiveness of the tracheobronchial tree to various stimuli that result in reversible, paroxysmal (intermittent) constriction of the airways. It is the principal cause of chronic illness in children. It is a recurrent and reversible obstruction of the airways in which bronchospasm, mucosal edema, and secretion of and plugging by mucus contribute to significant narrowing of the airways and subsequently impaired gas exchange.
- i. triggers may include: hypersensitive response to allergens, certain foods; chocolate, milk, eggs, nuts, grains
- ii. allergies to: pets, dust, pollens, pollution, cleaners
- iii. exercise
- iv. infection
- v. emotional stress
- vi. weather/environmental vii. cigarette smoke, wood-burning stoves
- i. A history, physical examination, and response to bronchodilator therapy are the first diagnostic tools.
- ii. an elevated level of eosinophils
- iii. allergy skin testing and a radioallergosorbent test (RAST) to identify sensitivity to allergens
- iv. exercise testing and PFT’s (pulmonary function test)
a. Manifestations: Obstruction is more severe during expiration because the airways become smaller during this phase of respiration. The trapped air in the lung causes hyperinflation and results in an increase in the effort needed for breathing and can eventually put a strain on the heart. The hypoxia and resulting acidosis can then cause general pulmonary vasoconstriction that damages alveoli, decreases, surfactant, and causes a chronic respiratory problem.
a. In acute episodes patient coughs, wheezes, has difficulty breathing, particularly during expiration. May complain that chin, neck, or chest itches. Signs of air hunger. Restlessness, perspires, and at times complains of abdominal pain. Pulse and respirations increase. Rales may be heard in the chest. Inflammation of the nose and sinuses may accompany asthma.
when do astma attacks usually happen?
a. Attacks often happen during the night. Repeated attacks over a long period may lead to emphysema.
- a. Chronic asthma is manifested by discoloration beneath they eyes, slight eyelid eczema, and mouth breathing.
- i. sudden or gradual onset
- ii. rapid and labored breathing
- iii. nasal flaring iv. productive cough
- v. expiratory wheeze \
- vi. use of accessory muscles
- vii. respiratory fatigue
Asthma Treatment and long-term managemen
- Prevention is the key!
- i. bronchodilators
- 1. Albuterol & Atrovent, metaproterenol (Alupent), and terbutaline (Brethair), used for long-term management for children; these usually inhaled using a nebulizer or MDI
- 2. salmeterol (Serevent), a long-acting bronchodilator used to prevent nighttime symptoms and for exercise-induced asthma; it is usually inhaled with an MDI
- 3. Theophylline is given orally, usually at night, in a liquid, tablet, or powder given with applesauce. Remember about periodic serum level checks for toxicity
- 1. Cromolyn sodium (Intal) used a prophylactic, or preventative. Cannot be used as a therapeutic drug for the emergency care of respiratory distress. It is prescribed before exercise if a child has exercise-induced asthma. Daily doses are prescribed to ensure an adequate blood level
- 2. nedocromil (Tilade), anti-inflammatory
- 3. corticosteroids: decrease inflammation; inhaled have fewer side effects that oral
- 4. leukotriene modifiers: block inflammation and cause bronchodilation
- 5. zafirlukast (Accolate), zileuton (Zyflo), and montelukast (Singulair) are used in older children with other medications for long-term use omalizumab (Xolair) is used for adolescents with allergic asthma and is given by monthly subQ injection
- a. Broad classification of upper airway illnesses
- i. Result from swelling of larynx
- ii. Spasmodic Laryngitis, Acute Laryngotracheobronchitis
- a. Swelling usually extends into the trachea and bronchi
- a. Clinical Manifestations
- i. Child ill for several days
- ii. Hoarse, “seal-like” barking cough
- iii. Fever may be present
- iv. Tachypnea v. Inspiratory stridor (shrill & harsh sound)
- vi. Anxiety
- vii. Below vocal cords
1. Croup Treatment & Nursing Care
- i. Child ill for several days
- ii. Hoarse, “seal-like” barking cough
- iii. Fever may be present
- iv. Tachypnea
- v. Inspiratory stridor (shrill & harsh sound)
- vi. Anxiety
- vii. Below vocal cords
Croup Nursing Care
- i. Airway Management
- ii. Calm child & family
- iii. Hydration
- iv. Educate family
Croup Parental Education (when to come to the ED)
- i. No improvement after taking outside or providing cool air treatment
- ii. Breathing is rapid & labored
- iii. Cyanosis
- iv. Persistent – symptoms continue
- v. Abnormal history (aspiration?)
- a. Flap @ opening of larynx \
- b. May close off trachea
- c. Most common cause: Haemophilus influenza (Hib
- d. Ages 3-6 yrs most common
- e. Rare
1. Epiglottitis clinical manifestations
- a. Clinical Manifestations & Diagnosis
- i. Can progress quickly – emergent
- ii. Sore throat
- iii. Dysphasia (difficulty swallowing)
- iv. Fever
- v. Drooling
- vi. Tripod position
- vii. Irritable
Epiglottitis Treatment & Nursing Care
- i. Airway management
- 1. Comfortable positioning
- 2. Oxygen, cool mist, don’t agitate
- 3. Rapid intubation or tracheostomy ii. Antibiotics iii. Hydration iv. Support of pt and family
- a. Most frequent hospitalization
- b. Greatest threat to infants
- c. Caused by inflammation and blockage of small airways
a. RSV transmission
- i. Droplet
- ii. Direct, close contact
- iii. Virus invades lungs and clogs bronchioles
- iv. Causes increased mucus secretion
- v. Causes decreased gas exchange and hypoxia
- vi. Most kids get it by age 2, worse in children < 6 months
RSV Clinical Manifestations
- i. Nasal stuffiness and nasal flaring
- ii. Persistent cough \
- iii. Fever
- iv. Rapid, shallow breathing, retractions
- v. Wheezing vi. Ill appearing, irritable
- vii. Barrel-shaped chest from trapped air
1. Retractions breathing locations
- a. Occurs in the accessory muscles
- i. Supraclavicular ii. Suprasternal iii. Intercostal
- iv. SubsternalSubcostal
- a. Sink in of soft tissue relative to cartilaginous and bony thorax
Retractions, whats the rule for high and low/\?
a. Higher the site, higher the problem!
breathing retractios, what is an indication that is better/ worse
- a. Higher the site, higher the problem!
- More sites, bigger problem
breathing rectactions treatment:
- Nutritional evaluation
- Suction before meds!!
a. Nursing Care for respiratory contractions
- i. Maintain respiratory function1. Suction2. Oxygen
- 3. Bronchodilators, steroids, ribavirin (mist tent), synagis (surfactant)
- Support parents
- Educate on treatments and procedures
1. Cystic Fibrosis (CF) Pathophysiology
- · Cystic Fibrosis is most prevalent in persons of northern and central European descent. It is an inherited recessive trait, with both parents carrying a gene for the disease. There is a deficit on chromosome 7. ·
- The basic deficit in CF is an exocrine gland dysfunction that includes increased viscosity of mucous gland secretion and a loss of electrolyte in sweat because of an abnormal chloride movement.·
- Thick Mucus causes obstruction of pancreatic enzymes and poor absorption of nutrients, flatulence, and foul smelling stools.
Cystic Fibrosis; pancriatic involvement -
- § Changes occurring in the pancreas result from obstruction by thickened secretions that block the flow of pancreatic digestive enzymes. As a result, foodstuffs, particularly fats and proteins, are not properly digested and used by the body.
- § In infants stools may be loose. Because of impaired digestion and food absorption, the feces of the child become large, fatty, and foul-smelling, and usually light in color.
- § The child usually doesn’t gain weight, and may look undernourished. The abdomen becomes distended and the buttocks and thighs atrophy as fat disappears from the main deposit sights.
- § A condition known as meconuim ileus exists when the intestine of the newborn becomes obstructed with abnormally thick meconium while in utero, this condition is caused by the absence of pancreatic enzymes that normally digest proteins in the meconium. The abnormal putty-like stool sticks to the walls of the intestine, causing blockage, the presentation of symptoms develop within hours after birth. The absence of stools and the presence of vomiting and of abdominal distention lead to suspicion of intestinal obstruction. X-ray films confirm the diagnosis.· Diet: Pancreatic enzyme replacement with normal meals.
1. Integration of the Nervous & Endocrine Systems
a. The two major control systems that monitor the functions of the body are the nervous system and the endocrine system. These systems are independent. The endocrine, or ductless, glands regulate the body’s metabolic processes. They are primarily responsible for growth, maturation, reproduction, and the response of the body to stress.
a. are chemical substances produced by the glands. They pour their secretions directly into the blood that flows through them. An organ specifically influenced by a certain hormone is called a target organ. Too much or too little of a given hormone may result in a disease state. Hormonal control is immature until at least 18 months of age, and therefore infants are more prone to problems related to the functioning of the endocrine system. Lethargy, poor feeding, failure to thrive, vomiting, and an enlarged liver may be early signs of an inborn error of metabolism in the newborn. The nurse must assess the effect on growth and development, advocate for early detection and intervention, and promote comprehensive follow-up care that will minimize complications.
1. Diabetes Insipidus
a. Diabetes insipidus can be hereditary (autosomal dominant) or acquired as the result of a head injury or tumor. It is the consequence of posterior pituitary hypofunction that results in a decreased secretion of vasopressin, the antidiuretic hormone. A lack of antidiuretic hormone results in uncontrolled diuresis. Polydipsia and polyuria are the initial signs. The infant cries and prefers water to milk formula. Loss of weight, growth failure, and dehydration occur rapidly. As the child grows older, enuresis may be a problem. Excessive thirst and the search for water overshadow the desire to play, explore, eat, learn, or sleep. Perspiration is deficient, and the skin is dry. Treatment involves hormone replacement of vasopressin in the form of desmopressin by subQ injection.
- i. Deficiency in in secretions of thyroid gland
- ii. May be acquired or congenital… Congenital=gland absent or not functioning. S/S sluggish &sleepy, enlarged tongue, noisy respirations, dry skin, no perspiration, hair becomes dry and brittle, cold hands and feet, Hypotonic “floppy” when handled, Chronic constipation, If symptoms left untreated, mental retardation and physical disabilities result.
- iii. One of the more common disorders in children
- iv. Screening test for hypothyroidism is mandatory in the U.s. and is performed at birth.
a. Juvenile Hypothyroidism
- i. Similar symptoms and diagnosis as congenital
- ii. Often appears during period of rapid growth
- iii. Mental retardation and neurological complications not seen if happens after age 3
a. Treatment for hypothyroidism:
- i. Synthetic hormone, sodium levothyroxine
- ii. Take at same time each day
- iii. Life long hormone replacement – educate parents
- iv. May take 103 weeks for therapeutic effect
a. Thyroid replacement cautions
- i. singns of too much thyroid replacement Rapid pulse rate, dyspnea, irritability,
- weight loss, sweating,
- ii. Signs of too little thyroid replacement Fatigue, sleepiness, ConstipationParents should be instructed about both.
1. Tay-Sachs Disease
- a. Deficiency of hexoaminidase, enzyme necessary for metabolism of fats
- b. Lipid deposits accumulate on nerve cells = physical and mental deterioration
- c. Found primarily in ashkenazic Jewish populations
1. Type 2 Diabetes Mellitus Pathophysiology
i. This is formerly known as non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset DM or maturity-onset DM: Type 2 DM involves a resistance to insulin. It is often aggravated by sedentary lifestyle and obesity. It also occurs more frequently in certain ethnic groups, such as African American and Pacific Islanders, especially those who have hypertension and elevated blood lipid levels. Acanthosis nigricans (a dark pigmentation in the flexor creases of the skin) may be a cutaneous marker for patients with type 2 DM. Table 31-3 lists the clinical features of types 1 and 2 DM. Lifestyle intervention is the cornerstone of preventing or delaying the onset of type 2 diabetes mellitus in susceptible individuals. The accepted criterion for diagnosing diabetes mellitus is a fasting blood glucose level of 126 mg/dL or higher.
1. Type 2 Diabetes Mellitus Manifestations
i. Children with diabetes mellitus present a triad of symptoms: polydipsia, or excessive thirst, polyuria, or excretes large amounts of urine frequently, and polyphagia, or constantly hungry. The symptoms may remain unrecognized until an infection becomes apparent or coma results. Laboratory findings indicate glucose in the urine, or glycosuria. Hyperglycemia (hyper, “above” gly, “sugar, “ and emia “blood”) is also apparent.
Type 2 Diabetes Mellitus Diabetic Ketoacidosis (DKA)
Is also referred to as diabetic coma, although a person may have DKA with or without being in coma. It may result if a patient with diabetes contracts a secondary infection and does not follow proper self-care. It may also occur if the disease proceeds unrecognized; this happens fairly often in children with diabetes. Even minor infections, such as a cold, increase the body’s metabolic rate and thereby change the body’s demand for insulin and the severity of diabetes. Ketoacidosis is the end result of the effects of insulin deficiency. Signs and symptoms include fruity odor to the breath, nausea, decreased level of consciousness and dehydration. Lab values include ketonuria, decreased serum bicarbonate concentration (decreased CO2 levels) and low pH, and hypertonic dehydration. Diabetic teaching should include this information.
Insulin Shock or Hypoglycemia
Children are more prone to insulin reactions because: the condition is more unstable in children. They are growing, and their activities are more irregular. Signs and symptoms of insulin reactions are: Irritability, poor behavior, pallor, hunger, weakness, and confusion.
Treatment of Hypoglycemia
Administer sugar in some form: Examples are orange juice, hard candy, or commercial products. Followed by a small amount of protein or starch. Glucagon is for severe hypoglycemia and it can be giving orally or intramuscluar injection.
i. The Somogyi phenomenon (rebound hyperglycemia) occurs when the blood glucose levels are lowered to a point at which the body’s counterregulatory hormones (epinephrine, cortisol, glucagon) are released. Glucose is released from the muscle and liver cells, which precipitates a rapid rise in the blood glucose levels. It is generally the results of chronic insulin use, especially in patients who require fairly large doses of insulin to regulate their blood glucose levels. Hypoglycemia during the night or high glucose levels in the morning is suggestive of the phenomenon. The child may awaken at night or have frequent nightmares and experience early morning sweating and headaches. The child actually needs less insulin, not more, rectify the problem.
Dawn phenomenon is early morning elevations of blood glucose occur without preceding hypoglycemia and may be a response to growth hormone secretion that occurs early in the morning hours. Together the Somogyi and dawn phenomena are the most common causes of instability in diabetic children. Testing blood glucose levels around 3 a.m. helps to differentiate the two conditions and aids in the regulating insulin dosage.
a. Management of Type 2 Diabetes Mellitus
- Dietis the main emphasis of management along with exercise and other weight controlmeasures. Insulin, oral hypoglycemic medications contribute to thestable control of blood glucose levels
- a. Include: exercise, skin care, foot care, infections, emotional upsets, urine checks, glucose-insulin imbalances, travel, follow-up care, and surgery.
1. Diabetes Type 1 Pathophysiology
i. This is formerly known as insulin-dependent diabetes mellitus (IDDM) and juvenile-onset diabetes mellitus. Type 1 DM is an autoimmune condition that occurs when a child with a genetic predisposition is exposed to an environmental factor such as a viral infection that triggers the syndrome by causing destruction of beta cells in the pancreas resulting in insufficient insulin production. In some cases, the beta cell destruction may be caused by drugs, chemicals, and ionizing radiation.
what is the Honeymoon period
i. When type 1 is initially diagnosed and the child is stabilized by insulin dosage, the condition may appear to improve. Insulin requirements decrease and the child feels well. This phenomenon supports the parent’s phase of “denial” in accepting the long-term diagnosis of DM for their child. The “honeymoon period” lasts a short time (a few months), and parents must be encouraged to closely monitor blood glucose levels to prevent complications.
a. Diet Therapy for Children with Diabetes Mellitus
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