-
What are s/s of respiratory distress for the infant?
- Restless
- Cyanosis (circumoral)
- Cough
- Dyspnea
- tachycardia
- Grunting
- Retractions
- Intercostal bulging
- Stridor
- head bobbing
- flaring of nares
- Clubbing (late sign)
- Chest pain
-
How is the pediatric respiratory system different from an adult's?
- lack of surfactant in premature infants
- Smaller Airway and underdeveloped cartilage
- Obligatory nose breather (infant)
- Less well developed intercostal muscles
- brief period of apnea (normal is <10 sec interval)
- Faster resp Rate
- Increased metabolic needs
- Eustachian tubes relatively horizontal
- Tonsilar tissue enlarged
- More flexible larynx (higher risk for collapse)
-
What is Respiratory Distress Syndrome (RDS)?
- TH LEADING CAUSE OF RESPIRATORY FAILURE IN PRETERM INFANTS
- Infant is unable to keep lungs expanded and aleveoli open due to lack of surfactant
- Due to increase in pulmonary vascular resistance, the fetal circulation continues to shunt through the foramen ovale
-
What are the clinical manifestations of RDS?
- Appear shortly after birth, worsen over the first 1-2 days and then gradually improves
- CXR shows a ground glass appearance
- Apnea is seen as lung function worsens
- Hypoxemia and Hypercapnea
- Metabolic Acidosis & respiratory Acidosis
- Inspiratory or seasaw respirations
- Nasal flaring, expiratory grunt, inspiratory crackles, cyanosis, tachypnea
-
What nursing care can be done for RDS?
- Supportive care: adequate nutrition and hydration, neutral thermal environment, minimize heat and fluid loss
- Respiratory care: O2 Therapy with possible ventilation, maintain acid-base balance, administer Baractant through ET tube, intermittent suctions (<5sec at a time, monitor pulse ox
- If baby survives >96 hrs, survival rate is good
-
What is Bronchopulmonary Dysplasia (BPD)?
- Develops in premature infants following a period of intensive respiratory therapy thru mechanical ventilation
- Incidence is increased because of increased survival rates by premies onvents
-
What are the s/s of BPD?
- Most infants display signs of respiratory distress
- May present with barrel chest
- CXR shows hyperinflation and opacities
- Infants will need vent support and supplemental O2 therapy for more than 28 days
-
What treatment is done is for BPD
- Treatment is really PREVENTION of the factors contributing to BPD
- -Reduce incidence of preterm delivery
- -use oscillating vent
- -get off vent ASAP
- *Also, monitor for infection, vent and suction frequently, and feed high caloric foods
-
Describe Hypospadias, Epidspadias, and chordee and how they are treated
- Hypospadias-urethra terminates on the underside (ventral) surface of the penis
- Epispadias- urethral opening is on the top of the penis (dorsal)
- Chordee-pulls the penis downward in an arc, interfering with urination
- *all three are surgically treated within 6-15 mo of age (circumcision should wait until repair is complete)
-
What is the exstrophy of the bladder and how is it treated? What is the main concern?
- The anterior surface of the urinary bladder lies open on the lower abdomen allowing direct passage of urine to the outside
- *The main concerns are infection and trauma to the bladder!! Surgical repair should be done within 48 hrs (this condition is often accompanied by other anomalies
-
At what point in gestation do cleft lips and cleft palates occur? Which is more common?
- Cleft Lip: 4-7 wks gestation
- Clef palate: 7-12 wks gestation
- *Cleft lip is more common
-
What are some possible causes of cleft lip and palate?
cause is unknown, although alcohol, smoking and teratrogenics may be a cause
-
What is the main complication/risk for children with cleft lips and palates?
- The main complication is trouble feeding, as the food may go into the nasopharynx with cleft palate, leading to aspiration and infection
- For children with cleft lip, it may cause difficulty feeding leading to poor growth
- Otitis media is common
-
How are cleft lips and palates treated?
Multidisciplinary Surgical repairs are done within the first year of life
-
What nursing considerations should be made post op for a cleft lip or palate repair?
- Do not suction by mouth
- Logan's bar across lip to hold it in place and prevent stretching
- Elbow restraints (called no nos) to keep hands away from face and mouth (may be restrained for 2-3 weeks)
- A breck feeder may be used to feed the infant orally past the incision
-
How are an infant's gastrointestinal system different at birth?
- Mechanical functions are immature at birth:
- -No voluntary swallowing until 6 weeks
- –Decreased stomach capacity
- –Increased peristalsis; faster emptying time
- –More prone to diarrhea
- –Relaxed cardiac sphincter contributes to tendency to regurgitate food
- -Gastric acidity in infants
- -Decreased saliva leads to decreased ability to digest starches
- -Liver functions immature thru out infancy
-
What assessments can be done to determine a gastrointestinal anomaly in an infant?
- What is the presenting problem?
- Vomiting- type, color, amount, pattern
- Abnormal bowel habits
- Wt loss or growth problem
- Food intolerances and normal feeding schedule
- Pain & its effect on sleep, play, feeding
- Parental Concerns
-
What specific assessment are important when performing a physical exam on the gastrointestinal system?
- Bowel sounds (should be q10-30sec)
- Liver margins (1-2 cm right costal border)
- Pancreas (1-2 cm left costal border)
-
What considerations need to be taken when using an NG tube for an infant or child?
- Use an infusion pump for continuous feedings
- If using gravity feedings, use correct height to time feedings about 20-30 min per feed
- Check the tube placement by auscultating air input q4hr
- Check residuals and refeed q3-4hr
-
What considerations should be made for infants on TPN?
- Use central venous line for high glucose solutions
- Check infusion rate q30 min as infants overload quickly
- Monitor urine glucose & ketones q4hrs for the first 24 hrs after solution change, then q8hrs
- Monitor for hyperglycemia (N/V, dehydration)
- Provide with pacifier to satisfy sucking needs
- Sterile dressing changes as per agency protocol
-
What is NEC? What factors contribute to NEC?
- Necrotizing Enterocolitis is an acute inflammatory disease of the bowel in preterm and high risk infants
- Occurs when the GI tract suffers vascular compromise
- Factors contributing to NEC include: prematurity, intestinal ischemia, colonization of pathogenic bacteria, substrate in the intestinal lumen (residual feedings in intestines)
-
What diagnostic testing reveals NEC?
- X Ray: appears like sausage dilation of the intestine with a bubbly appearance and thickened bell wall
- Lab Studies: anemia, leukopenia, metabolic acidosis, electrolyte imbalances, decreased platelet count
- DIC
-
What are the clinical manifestations of NEC?
- Apnea and bradycardia
- Temp instability
- Lethargy
- Abdominal distention
- Bile-stained emesis or gastric residuals
- Bloody Stools
- Visibly distended bowel loops
- Decreased or absent Bowel Sounds
- Abdomen tender under palpation
- Hypotension or shock
-
What is the therapeutic management for NEC?
- NPO for 24-48hrs if birth asphyxiated and/or VLBW, ELBW
- Breast milk is the preferred feeds for PO foods as it contains IgA immunities, macrophages, and lysozymes
- NG tube for decompression
- IV antibiotics, parenteral fluids, TPN
- Bowel resection if perforation occurs
-
What is the key concern with gastrointestinal anomalies?
Most interfere with normal nutrition and digestions that are essential to normal growth and development
-
What is esophageal atresia and tracheoesophageal fistula (TEF)?
- Esophageal atresia is when the esophagus ends in a blind pocket and is not connected to the stomache
- Tracheoesophageal fistula is when the esophagus and trachea lead to the wrong part (ex:trachea leads to stomach, esophagus leads to lungs, esophagus leads to both stomach and lungs)
-
What is the most common TEF?
Proximal part of the esophagus ends in a closed pouch and the distal part communicates with the trachea at a bifurcation
-
What are the s/s of TEF?
- Choking- due to blind pockets and fistulas leading to lungs or stomach
- Cyanosis- due to resp distress
- Coughing- oral secretions accumulate quickly
-
What is pyloric stenosis?
Hypertrophy of the circular muscle of the pylorus in stomach leading ti a obstruction at the distel end of stomach
-
What are the s/s of pyloric stenosis?
- Presents around 3 weeks of life
- Projectile vomiting (key)
- No bile
- Ravenously hungry
- Constipation
- Gastric peristaltic waves from left to right
- Irritable, weight loss, dehydrations
-
How is pyloric stenosis diagnosed and treated?
- Diagnosed by ultrasound/xray/barium swallow
- Treated surgically with a pyloromyotomy
-
What is Hirshsprung disease?
Also called obstinate constipation, its the absence of parasympathetic ganglion cells (nerves) within the muscular all of the distal colon and rectum
-
What are the s/s of Hirshsprung disease and how it is treated?
- s/s include absence of meconium within 24 hrs and constipation along with a distended abdomen
- Treated by surgical resection of the nerveless portion of bowel, with possible colonoscopy
-
What is Meckel Diverticulum? How is it diagnosed? How is it treated?
- The most common congenital malformation of the GI tract which is a remnant of fetal omphalomesenteric duct resulting in a fistula connecting the small intestine to the umbilicus
- This can cause bleeding (red currant jelly stools), intussusception, intestinal obstruction, diverticulitis, and perforation
- Diagnosed by a meckel scan and treated by surgical removal of the diverticulum
-
What is intussusception? What are the s/s?
- Invagination or telescoping of portion of bowel ileum and colon (from above downward)
- This is most frequent cause of abdominal obstruction
- S/S include currant jelly stools, vomiting, and shock
-
How is intussusception diagnosed and treated?
- Diagnosed by symptoms and sausage shaped mass in the abdominal wall
- EMERGENCY!!
- Treated by a simple reduction or resection, sometimes reversed by an air or barium enema
-
What is Malrotation and Volvulus of the intestines? what are the s/s? How is it treated?
- Malrotation of the intestine around the superior mesenteric artery
- s/s include intermittent vomiting, recurrent abd pain, distention, lower GI bleed
- May twist around itself and cause a volvulus, leading to necrosis, peritonitis, perforation and death
- Surgically treated to remove affected area, may result in short gut syndrome
-
What is an imperforate anus? How is it treated?
- Rectal pouch ends blindly at a distance above the anus and there is no anal orifice
- *Main s/s is no meconium within 24 hrs and abd distention
- Repaired surgically and may need a colostomy between procedures
-
Describe the different types of Hernias
- Diaphragmatic: abdominal organs are displaced into the chest through an opening in the diaphram
- -rapid labored respirations with cyanosis and rapidly worsening respirations
- -this requires emergency surgery and has a poor prognosis
- Hiatial: stomach pushes up into the diaphragm through the hiatial opening leading to reflux with small feedings. Treated with surgery
- Omphalocele: abdominal contents protrude through the root of umbilical cord and form sac on the abdomen.
- -Needs surgical treatment. Greatest concern is trauma and infection.
- -Maintain with wet sterile gauze
- Umbilical: usually close by age 3, can be detected if hard area larger than 2 cm around umbilicus. May be surgically treated
- Inguinal (male): small sac or peritoneum surrounding the testes fails to close off after testes descend from abd sac into scrotum
- -intestine slips into the inquinal canal and can cause swelling and strangulation of intestine leading to necrosis
-
What is Talipes Equinovarus?
- Congential Clubfoot
- Can be bilateral or unilateral
- Can be positional or syndromic
-
What is the non-surgical treatment for positional clubfoot?
- Serial Casting called Ponseti casting where the cast is changed every week for the first 23 weeks of life
- Denis Browne bar splint may be used
-
What is the surgical treatment for syndromic or congenital clubfoot?
- Lengthening of the achilles tendon
- Capsulotomy of the ankle joint
- Release of strictures
-
What is Congenital Hip Dysplasia and how is it diagnosed?
- Dislocation of the hip due to defective development of the acetabulum
- It can be diagnosed prior to the infant walking by the physician performing the Ortlani test and hearing an audible click or performing the Barlow test and the hip dislocates
- Also detected if the gluteal fold are asymmetric
-
How is congenital hip dysplasia treated?
- Treated by manipulating the femur into place and applying a brace
- Pavlivks harness needs to be adjusted weekly by a physician
- Frejka splint keeps the legs abducted
- Baby may be double diapered
- If the baby is 6-18 mo old, they may have an open reduction and a spica cast
-
What is spina bifida? What is spina bifida occulta?
- Spina Bifida: defect in the neural arch, generally in the lumbosacral region, leaving an opening through which the spinal meninges an spinal chord may protrude
- Spina Bifida Occulta: asymptomatic and presents no problems-dimple in the skin or tuft of hair over site may indicate its presence
-
What is the difference between spina bifida with a Meningocele and a Myelomeningocele?
- Meningocele: portion of the spinal meninges protrude through the bony defect and forms a cystic sac
- -no nerve roots involved and no paralysis or loss of sensation below area
- -Surgical removal of the sac is indicated
- Myelomeningocele: protrusion of spinal cord and the meninges, with nerve roots embedded in the wall of the cyst
- -sensory loss or paralysis below lesion
-
Many children with Neuro defects also have latex allergies- what foods may they also be allergic to?
Banana, avocado, kiwi, & chesnuts
-
Many children with spina bifida lose some form of bowel and bladder function; what medication can help create a voiding schedule?
Ditropan can help the bladder to extend further in order to adherance to a cathing schedule
-
What diagnostic test can be done during pregnancy to detect a neural tube defect?
An elevated alphafetoprotein is associated with neural tube defects
-
What is hydrocephalus and what is the difference between communicating and non communicating hydrocephalus?
- Excess CSF within the ventricular and subarachnoid space in the cranial cavity
- Non communicating is obstructive hydrocephalus
- Communicating is when the flow between the ventricles is not blocked
-
What are the s/s of hydrocephalus?
- excessively large head
- bulging fontanels
- rapidly enlarging suture lines with McEwen's signs (sounds like a broken pot when tapped)
- Scalp shiny with distended veins
- Eyes appear pushed downward (setting sun sign)
- S/S of ICP
-
How is hydrocephalus treated?
- ICP treated with manitol & dexamethasone (given with antacid)
- Shunting procedure to reroute extra CSF
- -Ventriculoperitoneal shunting
- -Ventriculoatrial shunting
- *increases risk of infection and onstruction
-
Describe neonatal seizures and what may cause them
- Usually a sign of a larger underlying cause
- Typically hypoxic ischemic encephalopathy
- Rarely organized tonic clonic seizures, although lip smacking and bicycle kicking may be evident
- May be caused by: metabolic imbalances, toxic syndromes, infections, trauma at birth, hypoglycemia, drug withrawal
-
How are neonatal seizures diagnosed?
- Serum electrolytes, CBC, blood glucose woll be taken
- EEG may be done
- CT and/or echoencephalogram
- Detailed neuro exam
-
How are neonatal seizures treated?
- Treat the underlying cause
- Respiratory support with 02
- Medications such as Phenobarbitol, dilatin, lorazapam, diazapam
- Document: length of seizure, body parts involved, type of movement, LOC, effect on color an resp status, post ictal condition
-
What are the three different kinds of meningitis?
- Bacterial: meniniococcus, pneumococcus, haemophilus influenza B, e-coli
- Tuberculous: caused by tubercle bacillus
- Viral: aseptic and caused by a variety of viruses
-
How is meningitis diagnosed?
- Elevated WBCs in blood and spinal tap (lumbar puncture) due to infection
- Decreased glucose and elevated protein in CSF
-
What are the clinical manifestations of meningitis?
- Fever
- poor feeding
- vomiting
- irritability
- frequent seizures
- Bulging fontanels
- Nuchal rigidity
- May have purpura or petechial rash
-
How is meningitis managed and treated?
- Should be on resp isolation 24 hrs past the start of antibiotics
- Admin antibiotics as soon as ordered
- Dexamethasone to decrease sequelae and prevent deafness
- Control seizures, fever and other complications such as shock and DIC
-
What is the prognosis for meningitis and what are some potential complications?
- The prognosis is dependent on the age, type fof rganism, and duration of illness prior to tx
- *highest mortality rate with pneumococcal
- Possible hearin loss due to damage to the 8th cranial nerve. This is assessed again at the 6mo follow up
- *preventable with Hib, pneumococcal, and meningococcal immunizations
-
What nursing considerations need to be made when caring for an infant with meningitis?
- Maintain isolation and quiet environment
- Elevate the HOB and avoid flexion of neck
- Seizure precautions
- Baseline HC at daily intervals
- VS, LOC, neuro signs and I/O q 1-2hrs
- Monitor for siadh
- Monitor daily weights
-
What are the s/s of increased cranial pressure (ICP)?
- Infants: bulging fontanel, irritability, high pitched cry, increased HC, distended scalp veins, changes in feedings
- Older Child: H/A, N/V, blurred vision, seizures, memory loss, lethargy
- Late Signs: bradycardia, decreased LOC and motor response, coma, cheyne stokes resp, changes in pupils
-
Describe Neonatal Abstinence Syndrome (NAS) and how it is diagnosed
- Withdrawal symptoms after birth due to exposure to addictive substances in utero
- Diagnosed by sample of hair, urine, or meconium to determine the substance (Screen on mother done as well)
-
What are the s/s of NAS according to the drug of withdrawal?
- Narcotics: loose stools, tachycardia, fever, projectile vomiting, sneezing, sweating
- Cocaine: neurobehavioral depression or excitability, IUGR and develop delays
- Nicotine: LBW, SGA
- Fetal alcohol syndrome: persistent growth retardation, malformations of face and skull, mental retardation
-
How is NAS therapeutically managed?
- early identification and intervention
- Drug therapy to reduce withdrawal
- Supportive treatment
- Mild sedation
- Monitor for malnutrition, dehydration, and electrolyte imbalances
- Frequent weights, I/O, caloric supplementation
-
What are inborn errors of metabolism?
- Inherited diseases-usually caused by a lack of hormones or enzymes
- Metabolism of carbohydrates, proteins, and or fats are affected
- Includes PKU, Hypothyroidism, galactosemia
-
What is PKU and how is it diagnosed?
- An autosomal recessive disorder that results in CNS damage from toxic levels of phenylalanine in the blood due to a deficiency in phenylalanine hydoxylase enzyme needed to convert phenylalanine into tyrosine
- Diagnostic eval: guthrie blood test from fresh heel stick is positive if phenylalanine levels >25mg/dL
- *this is a routine for all US infants
-
What are the s/s of PKU and how is it treated?
- Vomiting, seizures, FTT, irrtability, mental delays
- Treatment includes removed phenylalanine from diet: no meat, no dairy, no nutrasweet. This is a lifelong process
- Special formula may be used or the baby may continue to breast feed
-
What causes hemolytic diseases of the newborn?
- ABO and Rh incompatibility with the mother
- The maternal antibody responds to antigens in the fetal blood, which leads to destruction of fetal RBCs and anemia
- Mother has O blood, baby has A, B, or AB
- Mother has Rh-blood, baby has Rh +
-
What are the clinical manifestations of ABO-Rh incompatibility and how it is treated?
- Jaundice appearing within the first 24hrs
- Anemia
- Hepatosplenomegaly
- Hydrops fetalis
- Treatment includes exchange transfusions for the baby (Can be done intrauterine)
- Transfusion reaction s/s include tachycardia, bradycardia, change in BP, rash, temp instability
- RhoGam can be given to mother at 28 weeks gestation to prevent Rh antibodies
-
What causes hyperbilirubinemia?
- Livers inability to bind bilirubin for excretion
- High bilirubin levels can penetrate and damage brain cells causing encephalopathy and death (called Kernicterus)
-
Describe the different clinical manifestations of hyperbilirubinemia
- Physiologic jaundice: appears first in the face, then the torso
- Breast feeding jaundice: occurs within 2-4 days of age
- Jaundice due to blood incompatibility: occurs within 24 hrs
- Early clinical signs include lethargy or irritability
-
How is hyperbilirubinemia diagnosed?
- Blood specimen by heal stick (be sure to turn off bili lights when taking specimen)
- Once bilirubin levels >5, you can start to see it in the face. Blanche skin to assess for jaundice
- Sclera, conjunctiva, oral mucosa in dark skinned infants may be assessed
- Treatment is usually started for bilirubin levels >14.6mg/dL
-
How is hyperbilirubinemia treated?
- Phototherapy with either bili lights or bili blankets
- Be sure to cover eyes if using bili lights
- Infant should be placed nude under lights without lotions
- Be sure to turn frequently and monitor thermoregulation
- Monitor fluid intake- baby may breast feed if bili levels <20
|
|