Health problems of the infant
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What are the two classifications of failure to thrive?
- Organic: A disease process ie celiac disease, Cystic Fibrosis, and CHD
- and non organic causes: No apparent cause, but maybe due to enough breast milk feeding or lack of bundling.
What are the clinical manifestations of FTT?
Listliss, maybe unresponsive to cuddling, less than five % growth chart for weigh, possibly high growth as well, avoidance of eye contact, no fear at strangers, hypervigilant, delay development, and feeding disorders.
What category does the FTT baby falls into?
What does rumination means? What should you ensure before diagnosing a patient with FTT? What kind of environment will the baby improve?
What kind of attitude is necessary?
- Difficult or irritable
- Voluntary regurgitation
- To rule out any possible systemic/congenital disorders
- A nurturing environment
- A non judgmental
What assessment must be done for a child with FTT
Complete history of the problem, diet history, feeding, stooling and sleeping patterns, psycosocial history, parent-child interaction, developmental assessment of milestones, safety, and a physical assessment (weigh, skin, hydration, vital signs, responsiveness, lab results.)
What is the treatment of FTT?
- Nutritional supplementation: Vitamins, minerals, caloric boosters, protein.
- Offer support: Home visits
- Psycosocial therapy, and parenting classes
- Daily/weekly weights
- May need feeding program rehab, structure feeding routine, offer solid foods first before bottle, be persistent with negative behavior, at least 10 to 15 minutes.
What vitamin increases the uptake of iron, and what decreases the uptake of iron?
Vitamin C increases it and milk decreases it.
What disease occurs due to protein deficiency? What disease occurs due to protein and calorie deficiency? What diseases occur due to vitamin deficiency? What disease occurs due to lack of mineral deficiency?
- -Rickets (D Calcium and Phosphorus) Scurvy (Vitamin C) BERIBERI (Vitamin B1) Pellagra (B3)
- -Iron deficiency anemia, and calcium deficiency
What does vitamin B do? What does vitamin C do?
- Give energy, decreases stress, good for neuro system, good for nerve transmission ,
- Vit C: promotes healing
What is the management for gostrointestinal disorders?
- Maintain adequate nutrition
- Improve fluid intake
- Monitor elimination
- prevent infection, promote skin integrity, sensory stimulation
How much percentage of water is a premie? infant? child? how much ECF is exchanged/day compared to 1/5th to an adult?
- 1/2 of childs ECF is exchanged/day
by what age does the GFR reach adult level?
2 years of age
What is the metabolic rate of an infant? Why is fluid less conserved in infants?
- 2-3x that of an adult
- there is less reserve, increased resp rate = more water loss, infants have greater body surface area per kg body weight, therefore there is greater fluid loss through skin
What is the average urine output for an infant? age 1-10? Adult?
- 5-10ml/hr (when sick 1-2mL/kg/hr)
- 1-10: 10-2ml/hr
- older: 35ml/hr
What are the common causes of diarrhea and gastroenteritis? What are the mild symptoms? Moderate-severe?
- *watch for dehydration
- Lactose intolerance
- infectious diarrhea: salmonella (no antibiotics, works it way out and may see bloody stools), shigella (may be from water contam. and same as salmonella), E.coli(seen in summer, fecal-oral route, public places/nursery), rotavirus (usually seen in winter, fecal oral route), giardia( Contam. water, can pass cyst [that form] in stool, lingering diarrhea, a few samples needed, and treated with flagyl), c-diff
- mild: loose stools
- moderate/severe: severely dehydrated to gravely ill)
What is the primary form of dehydration in children? what are the implications?
- there is a balanced deficit of electrolytes and water; major loss from ECF compartment; decreased circulating blood volume; symptoms of hypovolemic shock
- Na is normal at 130-150mEq/L
What are the implications of hypotonic dehydration?
electrolyte deficit exceeds water deficit; ICF more concentrated than ECF; fluid moves into cells; decreased circulation blood volume; symptoms of hypovolemic shock; more severe than isotonic; Na is less than 130; may occur when losses are replaced with plain or glucose water
What are the implications of hypertonic dehydration?
water loss is greater than electrolyte loss; due to larger loss of water or greater intake fo electrolytes; can occur from large amounts of salty broth or high protein NG feedings; na greater than 150; results in neuro changes; may occur when losses replaced with large amounts of solute (hypertonic formula) (replace fluids slowly)
What is determined as "mild dehydration"
3-5% weight loss in infants ; fluid loss <50ml/kg; P and BP normal; color pale; tears present; mild thirst; decreased urinary output; normal mm's and AF; cap refill is >2 secs; urine specific gravity > 1.020; normal behavior
What is determined as moderate dehydration?
6-9% weight loss; fluid loss of 50-90 ml/kg; P slighty increased; BP decreased 10mmHg; 2-4 sec cap refill; decreased turgor; color gray; dry m"s; decreased tears; thirsty; Oliguria- sp grav greater than 1.020; AF normal- sunken; irritable
what is determined as severe dehydration?
> 10 weight loss- fluid loss> than 100ml/kg; mottled skin; tenting; skin cool; cap refill > than 4 seconds; P rapid and thready and orthstatic BP; absent tearing; sunken eyes and AF; mm's parched; oliguira or anuria; skin starts to crack; hyperirritable to lethargic
What are the complications of dehydration?
hypokalemia, hypocalcemia; hyponatremia; hypovolemic shock
What are early signs of hypovolemic shock?
mild tachycardia; normal BP; thirst; pallor; irritability; apprehension; decreased urine output; minimum urine output (1-2cc/kg/hr); decreased cap refill in hands and feet
What happens with hypovolemic shock?
- hypotension --> tissue hypoxia--> apnea
- increased RR to compensat for metabolic acidosis
- skin is cold and clammy
- decreased central venous pressure
- altered LOC
- decreased glomular filtration rate; decreased urine output (of it gets lower than 1-2cc/kg/hr, renal failure can occur)
How should you rehydrate for severe dehydration?
IV LR 40ml/kg/hr until P and LOC return to normal
How should you re-hydrate for moderate dehydration?
Oral re-hydration solution(sodium chloride) 100ml/kg over 4 hours
How do you re-hydrate for mild dehydration?
ORS 40-50ml/kg over 4 hours
How should you maintain/replace fluid losses due to loose stool?
- replace stool losses in addition to maintenance fluids 1:1 of stool losses are known
- 10ml/kg for infants for each diarrhea stool
- Older child replace each diarrhea stool with 100-250 mlwith 100-250ml
Daily volume of maintenance hydration should not exceed how much?
The maintenance fluid per 24 hour is determined by what?
if a child weighs 0-10kg how many mls/kg/day should he receive?
If a child weighs 11-20kg how many ml/kg/day should he get?
for the first 10kg 1000ml, then add 50ml for each kg over 10
If a child weighs > 20kg how many mls/kg/day should he receive?
1500kg for 1st 20kg then add 20ml/kg for each kg over 20
What are the diagnostics of dehydration?
- elevated HCT
- elevated BUN - decreased renal circulation
- CBC- increased bands with bacterial infections
- decreased Na and K
- stool with low pH and sugars; disaccharide intolerance
- leukocytes in stool if enteroinvasive organism
What are the nursing interventions for dehydration due to diarrhea and gastroenteritis?
- 3 stool specimens for C&S; strict I&O; weigh stools; daily weights
- establish normal fluid and electrolytes
- maintenance plus replacement fluids
- may be NPO to give bowel a rest
- BRAT diet may be used
- re-introduce fluids slowly
- antibiotics are not often ordered
to reintroduce oral fluids what do we use for children under 2? infants? over 2? what should we not use?
- pedialyte for children under 2
- if infant tolerates pedialyte, may give HALF strength formula, lactose free formula, or breast milk
- child over 2 can use ORS, weak tea, or flat soda and may continue regular diet
- We should not give: broth, Cow's milk, water, glucose water, jello, fruit juices, carbonated soda, high sugar fluids, anti-diarrhea meds
You should notify the MD if U.O is absent for how many hours? What is considered a normal stooling pattern? voiding pattern? what is the minimum "OK" # of voiding?
- 6 hours
- stools: <4/day
- Voiding: 6-10 at least 3-4 wet diapers/day
What is the prevention of diarrhea?
- tech personal hygiene: moat dia. is spread by the fecal oral route
- clean water supply: protect from contamination
- careful food prep
- hand washing
What is the definition of colic?
crying for more than 3 hours a day more than 3 days/ week; it is self limiting
what should you first rule out with colic?
allergy to: cow's milk, mom's diet, smoking; cns immaturity
What meds are used for colic? and what can be done to help soothe infant?
- milicon drops, gripe water
- change postion often
- pump legs
- turn baby belly down on arm
- warm bottle on abdomen
- small frequent feedings
- light massage
What is the difference between gastroesophageal reflux and GERD?
With GER there is no tissue damage
Who does GER occur in? What makes it abnormal? What % of infants have GER? when does it usually resolve by? What cause it? What causes the symptoms?
- GER occurs in everyone
- Frequency and persistence make it abnormal
- 50% of infants < 2 mo have GER
- it usually resolves by 12 mo
- it occurs from relaxation of the lower esophageal sphincter
- symptoms caused by inflammation from acids
How is GER diagnosed?
- history and Physical
- Upper GI series can detect pyloric stenosis, malrotation, hiatel hernia, strictures
- 24 hr intra-esophageal pH monitoring study
What is the treatment of GER?
- thicken feedings with 1tsb- 1 tbls of rice cereal/ oz of formula
- upright position past feedings
- prone position may be recommended is severity of GER outweighs the risk of sids
- tagamet, zantac, pepcid, prevacid, prisolec
- Nissen fundoplication ( surgical procedure that wraps the gastric fundus around the esophagus )
common childhood anemias result from what?
inadequate production of RBCs or hemoglobin, excessive blood loss, or both
What are the common types of anemia in children?
- iron deficiency
- hemolytic (congential)
- hemolytic (acquired)
prolonged and severe anemia can lead to what?
retardation: mental, growth and sexual maturity
when is iron deficiency anemia most common? why?
12- 36 months because fetal iron stores last only 5-6 months
what is the h & h seen in iron deficiency anemia?
- Hemoglobin: <11g/dl
- Hematocrit: 33%
How can we avoid/treat iron deficiency?
- improve nutrition with iron fortified cereal and formula; ferrous sulfate stains teeth
- for severe anemia may need inferon IV or IM; transfusions
in what nationality is sickle cell most commonly seen?
afrcan american and hispanic
When both parents are carries of a sickle cell trait what is the possibility of the child getting sickle cell anemia?
Newborns with sickle cell anemia are generally?
the clinical manifestations of sickle cell are a result of what?
an obstruction of sickled RBC and their destruction
What happen with sickle cell that results in pain? What does this lead to?
- a back of of entangled RBC in micro-circulation that causes vaso-occlusion. The absence of blood flow leads to hypoxia which leads to tissue ischemia which leads to infarction/tissue death.
- All of this leads to tissue death and scarring of tissue which could increase risk of stroke
When is a transfusion indicated for sickle cell?
when Hemoglobin is 7
In sickle cell this crises is known as painful episodes
In sickle cell what is a sequestration crisis?
pooling of red blood cells in the liver and spleen
In sickle cell this crises is known as diminished RBC production
In sickle cell is a hyper-hemolytic crises?
accelerated destruction of RBCs
In sickle cell, what causes a cva?
an entanglement/ block of major vessels in the brain
In sickle cell, what is acute chest syndrome?
similar to pneumonia
Why is sickle cell a mandatory newborn screening?
because early diagnosis enables initiation of appropriate interventions to minimize complications
If SCD is not diagnosed early, when do s & s appear?
in infancy following acute respiratory or GI infections
What is used to diagnose sickle cell?
- HgB elctrophoresis-fingerprinting of the protein
- Sickledex- a finger stick (results are obtained in 3 minutes; a positive test results indicate a need for Hgb elctrophoresis)
What is the goal with the treatment of sickle cell?
prevention of crises
What is the treatment of SCD?
- maintain hemodilution
- emergency: adequate hydration, minimal energy expenditure and O2 use, E-lyte replacement, analgesics for pain, blood transfusion, antibiotics if infection, O2 therapy
Some SCD patients need monthly blood transfusions, what is a complication of this and what is used to treat it?
iron build up in blood, the body can't excrete it, the pt needs a kelating agent to bind with the iron and help body to excrete it
What is hydroxyurea and what is it used for?
is a antineoplastic drug; it is used to help promote fetal hemoglobin
What viruses cause acute nasopharyngitis? (common cold)
rhinovirus, RSV, adenovirus, influenza virus
older than 3 months may show what symptom of nasopharyngitis compared to a child who is younger?
3 mo may have high fever, younger is afebrile
Which medication is not given to infants for nasopharyngitis?
ASA due to Ryes syndrom
decongestant drops should be used no more than _____ days for infants older than 6 months; why?
no longer than 3 days, may have rebound effect
What most commonly causes Otitis media?
what are the symptoms? What is the diagnostic? what is a myringotomy?
- RSV and influenza
- pulling at ears, acute pain, irritabilty
- otoscopic exam reveals bulging red or yellow eardrum, purulent drainage if ruptured, and if ruptured pain subsides
- laser assisted incision to relive middle ear fluid
What antibotic is usually given for OM? how long is the usual course?
amoxicillin; 10-14 days
What are the maifestations of OM with effusion? OME
- usually no pain, fever or bulging TM, immobile TM, orange discoloration, antibiotics only if it persists longer than 3 months
- a pressure equalizer tubes that facilitate drainage of middle ear fluid
What is the most common cause of acute bronchiolitis? when is it most commonly seen? at what age?
- RSV or respiratory syncytial virus
- winter/early spring
- seen in 1st 6 months of life and rarely after 2 years old
What is the pathophys of acute bronchiolitis?
- bronchioles are swollen tih mucus and exudate
- obstruction --> hyperinfaltion-->obstrctive emphysema-->patchy atelectasis
What are the clinical maifestations; diagnostics and treatment of acute bronchiolitis?
- S&S of URI, OM and conjunctivits may be present; tight cough, retractions, cyanosis, apne, barrel chest, may become dehydrated; hyperinflation on xray; increased pCO2--> resp acidosis & hypoxemia
- Diagnostics: nasal aspiration/ washing ( drops of saline, suction and send to lab to ID + RSV)
- Treatment: fluids and rest, humidified O2, maintain pulse ox > 90, periodic suctioning, bronchodilators may be ordered (albuterol/ zopinax)
- contact isolation, hand washing, ribavarin
What is Ribavirin?
A controversial med administered via aerosol treatment; limited to high risk infants and at the discretion of MD- category X drug; efficacy undetermined, pregnant caregiver not to be in room when given
How can RSV be prevented?
Palivzumab (syergist) monoclonal anitbody IM monthly for high risk children, infants with BPD, and those with congenital heart disease, infants born < 32 weeks; given monthly for RSV season from Nov - March
What is the usual cause of pnemonia in child 5-12? What causes SARs? What type of precaution are they on?
- mycoplasma and chlamydia
- caused by corona virus
- put on contact and airborne precautions and in isolation rooms
who is pneumococcal pneumonia most commonly seen in? why?
in infant (vaccine is given at 2 months) and children
What are the clinical manifestation of pneumonia?
- abrupt onset of high fever
- marked resp distress ( flaring, retractions, circumoral cyanosis) tachypnea/cardia, cough, chest pain, meningeal symptoms, pain is referred to abdomen, abd distention do to swallowing of air or paralytic ileus
What is SIDS? what are the risk factors? what characteristics are similar when finding infant?
Sudden infant death syndrome, the sudden death of an infant under 1 that remains unexplained after complete postmartum exam, including an investigation of the scene and review of hx; it is the 3rd leading cause of death in infants from birth - 12 months and the leadig cause of death from 1-12months
frequently between 2-3months, lbw, winter, male, low socioeconomic, mothers <20, mothers smoke, not firstborn, sleeping in prone position
infant is disheveled in bed, blankets over head or huddled in corner, mouth with frothy blood tinged fluid, infant lying face down, diaper full of urine and stool, hands may be clutching sheet, autopsy ay reveal mild resp distress
What are the common theories suggested of the causes of sids?
- brainstem abnorm in regulationg cardio-respiratory control
- smoking in home
What is ALTE?
- apparent life threatening events ( apnea of infancy)
- lasts longer than 20 seconds must stimualte infant, there is a color change (pallor or cyanotic) hypotonia, choking or gagging, slight increased risk for sids, R/o other diorders,, continuous home monitoring, and tech cpr
What is a hydrocele? Cryptorchism? Orchiopexy?
- collection of peritoneal fluid that accumulates in the scrotum, if persists for 1 year surgery is indicated
- Crypto: an undescended testicles; if not corrected sterility can result
- Orchiopexy: surgical procedure to bring testes down; usually done between 1-2 years of age
What is the most common cause of UTI? What are the symotoms? treatment? prevention?
- E. coli
- sympt: fever, irritablity, darkened urine, frequency
- Tx: antibiotics if pyelonephritis, hospital for IV hydration and antibiotics
- Prevention: wipe from front to back, frequent diaper change, fluids, good hygien, no bubble baths, cotton uderwear, no hot tubs, encourage pee 3-4 hours, hand washing before and after
What is a Wilm's tumor?
adenosarcoma in the kidney region and is one of the most common pf the abdominal neoplasms in early childhood (under 2) prognosis is good with chemo and early detection; treatment is chemo, radiation and removal; you can see it bulging through abd wall, DO NOT palpate tumor (pieces can float away and metastasize)
What is a febrile seizure?
- a seizure that occurs with a febrile illness without a CNS infection or acute E lyte imbalance
- most common between 6-36 months; unknown cause; Temp is > 101.8
- Treatment: IV valium, rectak valium is drug of choice; tylenol for fever
- if a seizure lasts longer than 5 minutes parent should call 911 and report description of seizure, fever, recent illness and how long it lasted
What documentation is needed for seizures?
types of movements, duration, parts of body involved, pulse and resp rate, color, eye deviation
what are the complications of a head injury? What indicates leaking CSF? What should you assess for if there i a present subdural hematoma?
- increased ICP, cerebral edema, infection, brain damage, hemorrhage
- nasal secretions with glucose (halo sign) l
- assess for shaken baby syndrome
For a head injury when should parents seek treatment?
significant fall, loss of consciousness, amnesia, severe headache, fluids leaking from ears/nose, vomiting 3 or more times, confusion, unsteady gait, change in vision , neck pain, bruising below eyes ("racoon eyes" basilar fracture), pupils dilated, unequal or fixed (neuro emergency)
What nursing assessment/ interventions should be done for head injury?
- Stabalize spine, dressing for abrasions, NPO, pain assess ( do not give pain meds or sedatives), neuro checks q 4 hours
- observe for change in LOC they appear before changes in vitals; quiet room and ect
What is miliaria rubra?
- AKA prickly heat rash usually seen in skin folds and neck/belly
- may use corn starch, don't bundle baby so much and tepid baths may help
what is Diaper rash
- bright red rash that extends gradually. may see pimples. blisters, ulcers, large bumps or pus filled sores on scrotum, penis or labia
- promptly remove wet diapers, clean urine and poo off of peri area with nonirritating cleanser/ mild soap, wash skin folds frequently with water, air dry, apply barrier cream such as zinc oxide, disidin, A&D; use cornstarch to reduce friction
What is candidiasis?
thrush that leads to candida in diaper, red rash/patches with smaller patches around it; use nystatin cream
What is Seborrheic dermatitis
aka cradle cap, thickened dead yellow skin due to excessive sebum, may use mineral oil on at night and next day wash it and comb it with fine toothed comb & repeat;
What is impetigo?
bacterial infection on skin caused by Strep A; highly contagious; should not go to school; reddish macule that errupts easily leaving honey comb crust on face; do a warm soak or warm compresses of 1:20 aluminum acetate in water (Burow's solution) to remove crust then, apply antibiotic like bactroban; oral or parenteral antibiotics if case is severe
What is acute infantile eczema?
- characterized by pruritus and associated with a history of allergies that are inherited.
- lesions disappear if scratching stops; cannot be cured only controlled; assess for exposure to allergen ( med, food, soap, animals) may see dry rough skin, hypopigmentation of skin in small areas, pallor surrounds nose & mouth/ears, bluish discolor of under eyes.
- Keep skin hydrated with tepid baths, use emmolient cream right after bathing, avoid irritants;
- Antihistamines are used (hydroxyzine or diphenhydramine) antibiotics for treatment of infetions, topical corticosteroids to reduce flare-ups, nonsteroidal agent to reduce inflammation; avoid infection: keep nails trimmed, adminster antipruriticsl cleanse with mild soap and water
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