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What are s/s of respiratory distress for the infant?
- Cyanosis (circumoral)
- Intercostal bulging
- 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
What are the clinical manifestations of NEC?
- Apnea and bradycardia
- Temp instability
- 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
- 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
- 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?
- poor feeding
- 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
- 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