434 Exam 2

Topic 3

Chapter 41: Dehydration, Disorders of Motility

Dehydration
o Total output of fluid exceeds total intake
▪ Mild dehydration – loss of less than 5% (body weight) in infants and 3%
in children
▪ Moderate – loss of 5%-10% in infants and 3%-6% in children (irritable)
▪ Severe – loss of more than 10% in infants and 6% in older children
(Lethargic)
o The earliest sign is usually tachycardia & mottling
o CM: poor skin turgor, wgt loss, lethargy, and tachy
o Lab tests: Serum Bicarbonate (<13 mEq/L). Urine specific gravity and BUN are
unreliable assessments.
o Pulse increase and BP decreases
o Blood is thick, check for delayed cap refill
o Treatment: mild- oral hydration (over 4 to 6 hours), severe: IV fluids 0.9% NS

Table 41.2 and 41.3

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Disorders of Motility
o Diarrhea
o Acute diarrhea is caused by antibiotic (ABX) therapy & giardia lamblia
o Chronic is over 14 days
o Most pathogens that cause diarrhea are spread by the fecal-oral route from person
to person
▪ Close contact (day care centers) Hep A
o Rotavirus is the most important cause of serious gastroenteritis among children
o Most children are infected with rotavirus at least once by 5 years of age
▪ Immunization
o Education: regarding s/s of dehydration, skin care to prevent excoriation
o Treatment: mild- oral hydration, severe: IV fluids

o Constipation
o Structural disorders
▪ Hirschsprung’s disease (ribbon-like stools), strictures
● Lack of innervation often in lower portion of bowel, no peristaltic
waves causing chronic constipation, megacolon
● Lack of meconium in the neonate stage
● Absent ganglion cells of bowel, no movement in bowel
● Rectal sphincter fails to relax
● Treatment

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 o 1) One stage surgical treatment - trans anal pull-through
OR
o 2) Colostomy (temp) and then removal of aganglionic
section

o Systemic disorders
▪ hypothyroidism, hypercalcemia
o Medications that cause constipation
▪ antacids, diuretics, antiepileptics, antihistamines, opioids, iron
supplements
o Encopresis: Repeated and involuntary defecation in a child older than 4, may be
the result of constipation
o Management
▪ high fiber diet (popcorn), exercise, regular toileting habits after meals,
stool softeners, emotional support – helping child to feel in control

Gastroesophageal Reflux
o The presence of abnormal amounts of gastric contents in the esophagus, upper airways,
and tracheobronchial area.
o NO passage - red flag, mucous, choking, trying to insert NG tube and doesn’t go down
o can lead to inflammation and stricture of the esophagus
o Resolution of GER is often a maturational process
o Risk of aspiration- teach CPR to infant
o Treatment:
o Conservative:
▪ Positioning – elevating head of the bed
▪ Feeding thickened formula with rice cereal
▪ Feeding small, frequent meals
o Acid suppression and neutralization medications
▪ (Ranitidine – Zantac, lansoprazole – Prevacid, omeprazole – Prilosec)
o PT teaching:
▪ Positioning – hold infant in an upright position for 30 minutes following a
feeding
▪ Decreases stomach acid so it will not be as irritating if the child spits up
▪ Administer PPIs 30 minutes before breakfast and if a second dose is
prescribed – 30 minutes before the evening meal.
▪ Remind parents that they may not see results right away as it takes several
days for a steady state of acid suppression.

Acute Appendicitis
● Symptoms:

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 ○Anorexia,
○Child doesn’t seem “normal”,
○N&V, low grade fever
○Pain is diffuse at first then gradually localizes to RLQ (rebound tenderness)
■ McBurney’s point (pain in RLQ, rebound tenderness)
○ If pain is suddenly relieved without intervention, suspect perforation–can lead to
peritonitis
■ Ruptured Appendix
● Peritonitis
○ IV antibiotics
○ NPO, NG tube to low continuous suctioning
○ May have a drain placed in surgery
○ Pain management
○ Longer hospital stay
● LABS
○ CBC, UA, & CT
● Pre-Op:
○ NPO, IV therapy, ABX
○ Position of comfort
○ Prepare for surgery
● Post-Op:
○ Monitor VS
○ Maintain IV and then advance diet as tolerated
○ Assess for pain
○ Encourage ambulation
○ Monitor incisional site(s)
○ Discharge teaching

Inflammatory Bowel Disease

● Crohn’s Disease
○ Affects the whole intestine, no cure
○ s/s: abd pain that is worsened by eating (RLQ), growth retardation, wt loss,
diarrhea
○ Dx: CBC, stools for occult, ophthalmic exam (bearing down)
○ Tx: corticosteroid tx, abx, TNF, immunosupp
○ Goal: ↓bowel inf, correct nutritional def
● Ulcerative colitis
○ Recurrent inflammatory and ulcerative disease, only affects the large intestine

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 ○ s/s: frequent bloody stools, abd pain, anorexia, 10-20 lbs wt loss over 2 months
○ Dx: CBC, stool blood occult, colonoscopy w/ biopsy
○ Tx: antidiarrheal, corticosteroids, abx (rare), analgesics, immunosupp
○ NSG int: nutritional support, teach how to cope with stress and avoid triggers
● Biliary Atresia
● A progressive inflammatory process that causes bile duct fibrosis
● Signs and symptoms
○ Poor Wgt gain
○ Stools will be chalky and white d/t lack of bile pigment
○ Jaundice of skin and sclera
○ Increase liver enzymes
○ Enlarged liver and abdominal distention-later sign
● Treatment
○ Kasai procedure
■ Connects the bowel lumen to the bile duct
■ The Kasai procedure improves the prognosis but is not a cure
■ Most successful if performed before 10 weeks of age
■ If not identified early enough or Kasai is not successful – liver
transplant by age of 2
● Vitamin and calorie support
○ Needs fat-soluble vitamins - A, D, E, K
○ Special formula containing medium-chain triglycerides
○ Formula – used because significant fat malabsorption occurs with
cholestasis

Cleft Lip and Palate

● Separation of the midline opening of the palate
● Defect approximately 6-8 weeks gestation
● S/S: you can see and feel it, nasal distortion
● Complications
○ Speech diff, malocclusion (abnormal tooth eruption pattern), dental decay,
↓self-esteem and body image
○ Chronic otitis media- secondary to Eustachian tube dysfunction; may result in
hearing loss
● Interventions
○ Encourage parent to bond with kid, feeding difficulty (Haberman bottles)
● Treatment goal
○ Achieve lip competence to make it look natural and normal speech development
● Post op Care
○ No sucking (pacificiers, candy, straws)

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 ○ Clean sutures with NS
○ Pain meds, sit upright
○ Elbow immobilizers - Keep hands away from mouth (7-10 days)
○ Rinse mouth after feeds
○ Supine/position side lying opposite from the sutures
● Patient education
○ teach pt how to feed their kids, don't feed them too fast or slow, dont go over 30
mins
○ cannot breastfeed because nipple is too flexible-nipple bottles will deliver milk
effectively in throat
○ Special Needs Feeder
■ (Haberman) nipple- a squeeze bottle and a soft nipple with a valve,
prevents the baby from ingesting excess air during the feeding
■ compress bottle in time with the infant’s chewing motions
● Allow for rest periods
○ higher concentrated formula
○ more frequent not more calories
○ Emphasize on the parents need to spend time with their child, cleft lip can be
disturbing, so allowing them to express their feelings can meet emotional needs

Esophageal Atresia & Tracheoesophageal Fistula (TEF)

● Esophageal Atresia
○ Esophagus is not a continuous passage
○ If NG tube is not going in = esophageal atresia
● Tracheoesophageal fistula TEF
○ Esophagus and trachea are not separated = abnormal passage
● S/S
○ Three C’s of tracheoesophageal fistula:
■ coughing, choking, cyanosis
○ Excessive drooling, apnea, abdominal distention, ↑RR during feeds
● Treatment
○ Maintain patent airway (int/cont suction)
○ prevent pneumonia - elevating the head and NPO
● Surgical interventions
○ Thoracotomy, G-tube, ligation
■ Do X-ray

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Hypertrophic Pyloric Stenosis
● Stomach contents unable to empty (usually diagnosed at 4-6 wks) infant vomits in a
projectile way right after eating and then is hungry
○ Related to narrowing of pyloric sphincter
● Risk for metabolic alkalosis – treat pre-op
● Palpable hard, moveable, “olive” pyloric mass in the right upper quadrant felt many times
but not always
● Visible peristalsis and wgt loss
● Treatment:
○ Surgical correction
■ Pyloromyotomy
○ Laparoscopy
○ Incision is high risk for infection due to location in diaper area–fold diaper down
to avoid contamination
● Post-op:
○ Begin small feedings 4 to 24 hours post-op- clear liquids
○ Vomiting is normal 24-48 hours
● Keeps crying - give pacifier in mouth

Intussusception
● Colon folds itself--proximal segment telescopes itself to distal segment
○ Needs tx asap to prevent necrosis
● S/S
○ sudden cramps
○ severe pain where child draws up knees and screams
○ (crouching, 15-20 mins)
○ Sausage-shaped abdominal mass
○ jelly stool
○ bright red and mucus in stool
● Tx: barium enema-can repair and diagnose
○ If pt suddenly has normal brown stool, we need to call HCP, so he can
adjust tx because it might have self-resolved

Volvulus
● A portion of the intestine twists around itself
● Most often within the first 6 months
● Intense crying and pain
● Pulling up legs

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 ● Abdominal distension
● Vomiting, usually bilious
● Tachycardia and tachypnea
● Surgical emergency

Celiac Disease
● A genetic disorder in which gluten causes damage to the small intestine
● Villi of the small intestine absorb nutrients into the bloodstream – now damaged causing
malnutrition
● Only treatment – strict gluten-free diet
○ Gluten found in grains (wheat, rye, oats, barley)
○ Food choices: rice, corn, chia, flax, quinoa, fruit, meat/fish/seafood
○ no gluten- SATA question- corn, rice cake, meat
● even a small amount of gluten will cause damage to the villi
● Low Vitamin D level
● Celiac crisis – extreme vomiting and diarrhea. Requires IV therapy and electrolyte
replacement
● Signs and symptoms:
○ Steatorrhea (fatty stools)
○ Diarrhea and/or constipation
○ Vomiting
○ Failure to thrive or weight loss
○ Nutritional deficiencies
○ Anemia
● Treatment
○ Gluten free diet
○ Refer to nutritionist

Omphalocele and Gastroschisis

● Omphacele
○ Evisceration of abdominal contents in the external peritoneal sac
○ Defect varies in size
○ Usually detected on prenatal ultrasound
○ Try to push back in
● Gastroschisis
○ A herniation of the abdominal contents through an abdominal wall defect
○ No peritoneal sac protecting the herniated organs

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 ○ Exposure to amniotic fluid causes organs to thicken, become edematous, and
inflamed
○ Contagious for infection
○ Nursing Management
▪ Prevention of hypothermia
▪ Keep baby in a radiant warmer to maintain temperature
▪ Maintaining perfusion to the eviscerated abdominal contents by
minimizing fluid loss
▪ Covered with a non-adherent sterile dressing
▪ May require 2-3 times maintenance fluids to maintain perfusion
▪ Protecting the abdominal contents from trauma and infection
▪ Utilize strict sterile technique to prevent contamination
▪ Keep in a sterile bag or covering with sterile transparent dressing - to
decrease heat and fluid loss
● Surgical Management
▪ Occurs after initial stabilization
▪ May occur in stages, depending on the defect
● Obvious at delivery, may be present on US or mistake hematoma

Chapter 45: GU Dysfunction

Genitourinary Tract Disorders and Defects

● The young infant’s kidneys cannot concentrate urine as efficiently as older children or
adults because the loops of Henle are not long enough yet
● By 6-12 months, kidney function is nearly like that of an adult
● GFR=kidney function
● Under 60 is bad, under 15 is kidney failure

● UTI
○ Pt education for girls:
○ All natural cran juice
○ Hydrated
○ Wear cotton underwear
○ Avoid bubble baths (esp. girls)
○ Urinate frequently (at least 4 times/day)
○ Drink plenty of liquids (amount varies with age)
○ Change diapers often
○ Wipe front to back

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 ○ Regular bathroom schedule, proper hydration

● Enuresis
○ Dysuria, up to 5 y/o, should subside by 6
■ If not, contact HCP
○ Primary Enuresis
■ Urinary incontinence in a child who never has voluntary bladder control
○ Secondary Enuresis
■ Urinary incontinence in a child who previously had bladder control, lost it
○ Diurnal Enuresis
■ Daytime urinary incontinence
○ Nocturnal Enuresis
■ Nighttime urinary incontinence
○ Medication (Desmopressin) is last resort

● Vesicoureteral Reflux (VUR)

○ Urine from the bladder flows back up to the ureters
■ Increases risk for UTI
○ Renal scarring/
○ TX: antimicrobials, increase fluids, good hygiene, prophylactic abx, urine cultures

External Defects of the Genitourinary Tract

● Hypospadias
○ Urethral defect with opening on the ventral (under) surface of penis
■ Normal: at the end

○
● Epispadias
○ Opening on dorsal on top

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 ○

● Treatment
○ Do not circumcise at birth so that surgeon can use this skin when
correcting problem (may possibly be able to perform after repair surgery)
○ usually done by 18 months of age
○ If left untreated – may not be able to aim urine stream
○ Interferes with deposition of sperm – sterile
○ Affects self-esteem and body image
● Post Op
○ Urethral drainage catheter temporarily
○ Oxybutynin (Ditropan) given to relieve bladder spasms
■ Classification: Urinary Antispasmodic
● Mechanism of action: works directly on the smooth muscles of the
urinary tract by blocking parasympathetic nerve impulses
● Uses: urinary incontinence, neurogenic and overactive bladder
● Side effects: drowsiness, tachycardia, anticholinergic effects,
insomnia
● Phimosis
● Narrowing of the foreskin
● Swollen- can’t retract it- normal finding, child will outgrow
● Do not force retraction – could cause scarring and possible paraphimosis
● Steroid cream may be applied twice/day for 1 month
● Hydrocele
○ Fluid in scrotum - Common in newborns
○ Communicating – opening between scrotum and peritoneum
■ Can change in size during the day
○ Noncommunicating – no opening between scrotum and peritoneum
■ No change in size
○ Surgical repair if last past 12 months of age
● Cryptorchidism

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 ○ Undescended testicles (one or both balls haven’t dropped)
■ Common in premies (Tyler never really grew out of it)
○ Interventions:
■ Use warm hands to examine infant
■ Exam can be done in parents lap to aid comfort and cooperation in infant
■ Testes will retract normally if infant is cold or upset

Glomerular Diseases
Know the difference b/w acute glomerulonephritis and nephrotic syndrome!!

● Nephrotic Syndrome
○ Increased glomerular membrane permeability causing an abnormal loss of protein
in the urine (proteinuria)
● Three forms
○ 1) Congenital – rare with a poor prognosis without kidney transplant
○ 2) Idiopathic – most common
○ 3) Secondary – due to another condition/disease
● Manifestations:
○ proteinuria, hypoalbuminemia, edema, hyperlipidemia
○ Weight gain
○ Edema around eyes, hands and face
○ Growing waistline (ascites)
○ Nausea or vomiting (may be related to ascites)
○ Pale tight skin from progressing edema
○ Weakness or fatigue
○ Irritability or fussiness
○ SATA: Three F- frothy pee (proteinuria), facial edema, fatigue
● Medications
○ Prednisone (to initiate remission) corticosteroids
○ Diuretics
○ Antibiotics
● Child is in remission from nephrotic syndrome when urine is zero to trace for protein for
5-7 days

● Acute Glomerulonephritis
○ Immune process injure the glomeruli
○ Caused by streptococcal infection
○ Can progress to uremia and renal failure

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 ○
Inflammation of the glomeruli in response to a preceding illness
○
Streptococcal - upper respiratory infection (about 1-3 weeks after)
○
Strep –causes strep throat, impetigo
○
Occurs most in ages 2-12, more boys
○
Manifestations:
■ Dark brown color of urine from old blood
■ Excess fluid volume
■ Proteinuria (mild to moderate)
■ Abdominal pain
■ Hypertension, proteinuria, hematuria
■ Mild edema
■ Lung congestion – crackles
■ Decreased urine output
■ Lethargy
○ Treatment:
■ Antihypertensives
■ Diuretics
■ Antibiotics
■ Maintain sodium and fluid restrictions during initial edematous phase
■ Weigh daily, strict I & O
■ Bed rest d/t fatigue during acute phase
■ Emergency care – hemodialysis for renal failure
● Hemolytic Uremic Syndrome (HUS)
○ The swollen lining of the small blood vessels damages RBCs = ANEMIA
○ GI symptoms
■ bloody diarrhea, which suggests that an infectious agent may be the cause
○ TRIAD: Decrease RBC, renal failure, thrombocytopenia (low platelets)
■ Most are also associated with E. Coli
○ Other signs and symptoms:
■ Anemia
■ Fever
■ Abdominal pain
■ Low hemoglobin
○ Treatment:
■ Blood products
■ May require peritoneal dialysis- urine output is low to none

Renal Failure
○ A sudden, often reversible, decline in renal function

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 ○ Fluid overload may lead to hypertension, pulmonary edema, and congestive heart
failure
● Signs and Symptoms:
○ Oliguria and/or anuria
○ Azotemia (blood urea nitrogen [BUN] elevated)
○ Creatinine elevated
○ Hyperkalemia (weak irregular pulse, lower BP, abdominal cramps)
○ Increased phosphorus levels
○ Fluid retention and edema
○ Hypertension, cardiac arrhythmias
● Treatment:
○ Support body systems: cardiovascular, respiratory
○ Give insulin and glucose to help move potassium into cells to lower circulatory
level
○ Restrict protein + K + phosphorus + Na
○ Fluid restriction
■ But if they’re febrile, give more fluids
○ Aluminum hydroxide gel OR calcium carbonate to bind with phosphorus and
prevent absorption of it
○ Prevent infection
○ Support nutrition
● Indications for Dialysis in Acute Renal Failure
○ Severe fluid overload
○ Pulmonary edema or congestive heart failure secondary to fluid overload
○ Severe hypertension
○ Metabolic acidosis or hyperkalemia not responsive to medications
○ Blood urea nitrogen >120 mg/dl

● Dialysis
○ Separation and removal of solutes from body fluid by diffusion through a
semipermeable membrane
● Peritoneal Dialysis
○ Simpler but longer than hemodialysis
○ Fluid is introduced into abdomen, allowed to stay there 60 minutes to collect
waste products and then removed and repeated until BUN and creatinine levels
are normal
○ Can be done by parents/older children
○ Should not cause any cramping and fluid returned should be clear
● Hemodialysis

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 ○ Blood is removed from the body; an external membrane is used to diffuse out urea
and electrolytes before blood is returned to child.
○ 3 hours is as effective as 12 hours of peritoneal dialysis
○ Can be done OP 2-3 times a week for child with kidney failure
○ Erythema and pain could indicate an infection
○ Report to HCP of infection: inflammation around port

Topic 4

Chapter 40: Respiratory Dysfunction

General Aspects of Respiratory Infections
● **tobacco can cause ear infection
● Frog-croaking--need to intubate
● Asthma in infants – triggered by viral infection
● Retractions: the higher they are, the more dangerous they are
● Status asthmaticus NO supine
● CysFib affects lungs and pancreas
● RSV give o2 via NC
● S/s of resp distress: nasal flaring, cyanosis, grunting
● Kids have smaller airways, larger tongues (for feeding and sucking), thin chest
walls=fatigue easy, increased RR, fewer alveoli, no neck=intubation can be problematic
○ Need to count RR for a whole minute
● Kids are not covered with pertussis, so we need to emphasize the vaccine
● Day cares: hand washing!!
● CARE MANAGEMENT FOR RSP PROBLEM:
○ Ease resp effort
○ Promote rest, play quietly
○ Handwashing, prevent spread of inf
○ Reduce body temp by giving ibuprofen/acetaminophen (older than 6 months for
ibuprofen)
○ Provide family support and home care
■ Educate parents that cold meds may contain acetaminophen, so that they
don't double dose or OD
○ Proper nutrition and hydration

Respiratory Tract Infections

● Acute viral nasopharyngitis
○ Group A β-hemolytic streptococcal infection

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 ● Acute infectious pharyngitis (strep throat)
○ Diagnosis: throat swab
○ Med: Azithromycin
○ Risk for rheumatic fever (RF)
○ Child can return to school after taking antibiotics for 24 hrs
● Tonsillitis
○ Excessive swallowing = hemorrhage, seek care ASAP
○ Can’t have red things- Kool-Aid or juices
○ Tonsillectomy and adenoidectomy
○ No suctions or straws or oral care

● What is the most important consideration in managing the care of the child after
tonsillectomy or adenoidectomy?
○ Continuous swallowing = postoperative hemorrhage

● Otitis Media
○ s/s: pulling ear, purulent discharge, crying, refusal to eat, rolling head side to side
○ Higher risk for OM because they have shorter eustachian tube
○ TX: amoxicillin
■ Orally for 10 days, 5-7 days (6 year old)
○ Tobacco can cause ear infections

Croup Syndromes
● Characterized by hoarseness, “barking” cough, inspiratory stridor, and varying degrees of
respiratory distress
● Croup syndromes affect larynx, trachea, and bronchi
○ Acute Epiglottitis- a medical emergency – they will need to be intubated
○ Often caused from unvaccinated
■ Sore throat, pain
■ tripod positioning
■ Frog like stridor is really bad**
■ Drooling, difficulty swallowing
■ Absence of spontaneous cough
■ Inspiratory stridor, mild hypoxia, distress
■ Do not do throat inspection, only HCP can
■ Corticosteroids- epi
○ Acute Laryngotracheobronchitis (LTB)

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 ■ Most common
■ Affects children <5 years of age
■ CM:
● Usually preceded by an upper respiratory tract infection
● Inspiratory stridor
● Suprasternal retractions
● Barking or “seal-like” cough
● Increasing respiratory distress and hypoxia
● Can progress to respiratory acidosis, and respiratory failure
■ NI:
● Maintaining the airway
● Maintain hydration, orally or intravenously
● Nebulized mist with supplemental O2
● Nebulizer treatments
○ Epinephrine
○ Steroids
○ Tracheitis
■ Most often caused by H. influenzae type B

● Bronchitis- Tracheobronchitis
○ Mild, self-limiting disease
○ Cough, fluids, rest
● Respiratory Syncytial Virus (RSV)
○ Predominant in winter → summer time
○ Palivizumab (Synagis)
■ Give to high risk infants
○ Monthly injections until RSV season is over
○ Supplemental O2 via NC

Infections of the Lower Airways

● Pertussis (whooping cough)

○ Bordetella pertussis
○ Highest incidence in spring and summer
○ Highly contagious
○ Risk to young infants

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Asthma
● Kids have smaller airway - not narrow
● interventions
○ Allergen control
○ Drug therapy
○ Exercise
○ Breathing exercises
○ Hyposensitization
○ Status asthmaticus
○ SATA: Avoid allergens: tobacco smoking, irritants, perfume, odor, exposure to
chemicals, exercise, changes in temp, changing in school, strong emotions
○ Relieve bronchospasm
○ Peak Flow meters: assess asthma severity
■ Red is bad, green is good
○ Resp acidosis= retaining CO2
● Drug Therapy for asthma:
○ Metered-dose inhaler
○ Corticosteroids
○ Cromolyn sodium - long term control med- for children over 2
○ Albuterol: acute exacerbations & prevention of exercise induced bronchospasm
■ 2 inhales 5 minutes apart
■ Use a spacer if they can’t breathe in med effectively
○ Salmeterol (Serevent):
■ Long acting
■ Use: This drug is added to anti-inflammatory therapy and used for
long-term prevention of symptoms for children 4 years and older
■ Twice a day (every 12 hours)
○ Methylprednisolone- give in ED
■ Use: To gain prompt control of inadequately controlled persistent asthma
or to manage severe persistent asthma
■ Parenterally
■ Given in lowest effective dose
● Status asthmaticus: untreated asthma, medical emergency
○ Do not place supine
● Continuation of respiratory distress despite vigorous therapeutic measures
● If child is taking long-term inhaled steroids: assess for slowed growth
● Therapeutic intervention
○ Improving ventilation
○ Pharmacologic agents

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Cystic Fibrosis
● Multisystem involvement
○ Increased viscosity of mucous gland secretions
○ Elevation of sweat electrolytes
○ Increase in enzymatic constituents of saliva
○ Autonomic nervous system abnormalities
● Autosomal recessive trait
○ Defective gene inherited from both parents with an overall incidence of 1:4
● Increased viscosity of mucous gland secretion
● DX: chest x-ray and chloride sweat test
● S/S
○ Wheezing respiration, dry nonproductive cough
○ Generalized obstructive emphysema
○ Patchy atelectasis
○ Cyanosis
○ Clubbing of fingers and toes
○ Repeated bronchitis and pneumonia
○ Meconium ileus- small intestine blocked with thick, puttylike, mucilaginous
meconium
○ Distal intestinal obstruction syndrome
○ Excretion of undigested food in stool; increased bulk, frothiness, and foul odor
(Steatorrhea)
○ Wasting of tissues
○ Prolapse of the y
● Medications:
○ A, D, E K, Pancreatic enzymes
■ Administration: At the beginning of meals/snacks or within 30 minutes of
eating
■ capsules swallowed whole or taken apart with the enteric-coated beads
sprinkled on small amount of food, BUT DON’T CRUSH IT
○ Dose: Depends on the severity of the insufficiency; child’s response to enzyme
replacement; and practitioner’s philosophy. Usually, 1 to 5 capsules with meals;
smaller amount for snacks.

Epistaxis

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Chapter 42: Cardiovascular Dysfunction

Cardiovascular Dysfunction

Congenital Heart Disease

Atrial Septal Defect

● A passageway or hole in the septum that divides the right atrium from the left atrium
● If the ASD is small, many infants have a spontaneous closure within the first 18 months
of life.
● If it does not close spontaneously by the age of 3, the child will most likely require
surgical intervention.
● Most children are asymptomatic
● Increased pulmonary blood flow → pulmonary HTN → CHF
○ Acyanotic

Ventricular Septal Defect (VSD)

● Abnormal opening b/w L & R ventricles
● Oxygenated blood from LV → RV
● Increased pulmonary blood flow → CHF
○ Acyanotic
● Small VSD = asymptomatic

Patent Ductus Arteriosus

● Failure of the ductus to close (ductus = opening b/w aorta & pulmonary artery to receive
O2 from mom as a fetus)
○ Increased workload of the L side of the heart
○ Increased pulmonary blood flow → CHF

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 ■ acyanotic
○ S/S: continuous machinery like murmur
○ Indomethacin/ibuprofen (motrin) to close it
■ Indomethacin constricts vessels

Coarctation of the Aorta

● Narrowing of the aorta
● Blood flow is impeded, causing pressure to increase proximal to the defect and decrease
distally
● Blood pressure increases in the heart and upper portions of the body and decreases in the
lower portions of the body
● At risk for aortic rupture, aortic aneurysm, and CVA
● Lead to stroke, chest pain
● Infant’s PDA (patent ductus arteriosus) can help compensate in the first few hours before
it closes
○ Prostaglandin can be given to keep PDA open and counteract coarctation of the
aorta
● S/S
○ High BP in upper extremities, low BP in lower extremities
■ Need to take BP in all extremities
● Treatment
○ Balloon angioplasty

Tetralogy of Fallot
○ Tetralogy of Fallot
■ Composed of four heart defects:
● Pulmonary stenosis
● Ventricular septal defect (VSD)
● Right ventricular hypertrophy
■ Overriding aorta
● positioned more centrally so it takes blood from both aortas,
causing mixing of blood
○ S/S
■ Cyanosis
■ Decreased pulmonary blood flow

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 ○
■ If having hypercyanotic episodes (blue tet) = Calm the child, place the child in a
knee-chest position (helps venous return), administer O2 and/or morphine, and
supply IV fluids
■ At risk for dysrhythmias
● A nurse is teaching nursing students the physiology of congenital heart defects.
Which defect results in decreased pulmonary blood flow?
■ Tetralogy of Fallot

Tricuspid Atresia
● Valve between the right atrium and right ventricle fails to develop
● Foramen ovale and PDA must remain open to maintain minimally adequate oxygenation
● Cyanosis, difficulty feeding, tachypnea
● 3 stage surgical repair
● Blood returning from the systemic circulation to the right atrium cannot directly enter the
right ventricle due to agenesis of the tricuspid valve.
● Deoxygenated blood then passes through an opening in the atrial septum (either an ASD
or patent foramen ovale) into the left atrium, never entering the pulmonary vasculature.
● Deoxygenated blood mixes with oxygenated blood (via the PDA emptying from the aorta
to the pulmonary artery and becoming oxygenated) in the left atrium.
● S/S
● Can be cyanotic at birth or a few days later when PDA closes.
● History of tachypnea and difficulty with feeding
● Treatment
● Surgery – ends when systemic venous return is redirected to the pulmonary artery
directly

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Aortic Stenosis
● Caused by a muscle obstruction below the aortic valve, an obstruction of the valve itself,
or an aortic narrowing just above the valve. Too small
● Obstruction between left ventricle bc pumping too hard and aorta resulting in decreased
cardiac output → CHF
● Left ventricle hypertrophies
● Typically, asymptomatic
● S/S
○ Chest pain when active, dizziness with prolonged standing
● Interventions
○ Assess pulse, they may faint if severe
○ Balloon dilation via cardiac cath

Transposition of the Great Vessels

● Pulmonary artery and aorta are flipped
○ Pulmonary artery pumps from the left ventricle, aorta pumps from the right
ventricle instead of the other way around
● Aorta is sending oxygenated blood into the body, want PDA open
● Often diagnosed in the first few days of life
● Significant cyanosis if the PDA closes
● Corrective surgery performed at age 4–7 days
● Balloon atrial septostomy usually done as soon as diagnosed
○ Surgical correction – switching arteries into their normal anatomic position

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–

Hypoplastic Left Heart Syndrome

● All structures on the left side of the heart are severely underdeveloped
● Mitral and aortic valves are completely closed or very small
● PDA needs to be open to mix blood
● Left ventricle is non-functional
● Options of care – palliative care, cardiac transplantation within the first few weeks of life,
or three-stage palliative reconstruction surgery starting the first few weeks of life

Heart Failure
● Assessment:
○ s/s vary depending on type of failure
○ Activity intolerance
○ Poor feeding- no more than 30 mins
○ Abnormal weight gain
○ Hepatomegaly
○ Splenomegaly
○ Peripheral edema
● Diagnostics
● Chest x-ray – cardiomegaly and increased blood flow
● -ECG - ventricular hypertrophy
● Echo – determines the cause such as congenital heart disease or poor ventricular
function
● Treatment
○ Digoxin (Lanoxin)

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 ■ Improves contractility and myocardial efficiency
■ Beneficial effects include increased cardiac output, decreased heart size,
decreased venous pressure and relief of edema
■ Contraindications: DO NOT GIVE IF THE PULSE IS LESS THAN 90
TO 110 BEATS/MIN IN INFANTS AND 70 BPM IN OLDER
CHILDREN (REMEMBER THE CUT-OFF FOR ADULTS IS 60 BPM)
■ Infants do not receive more than 1 mL
■ Dig toxicity= N/V, brady, dysthymias
● Decreases potassium and heart rate
○ ACE inhibitors (Captopril, Enalapril, or Lisinopril) -
■ Inhibit the normal function of the renin/angiotensin system in the kidney.
This causes vasodilation which results in decreased pulmonary and
systemic vascular resistance, decreased BP, and a reduction in afterload.
○ Beta blockers (Carvedilol)
■ Block the alpha and beta receptors causing decreased heart rate, decreased
BP, and vasodilation
○ Diuretics
● Furosemide (drug of choice)
○ may need potassium supplements. Hypokalemia can cause dig
toxicity
● Possible fluid restriction
○ In acute stages of HF
● Possible sodium restriction
● Not used as commonly in children than adults d/t potential
negative effects on the child’s appetite and ultimate growth
Decrease cardiac demands
● Provide a neutral thermal environment to prevent cold stress in infants
● Treat any existing infections
● Reduce the effort of breathing
○ Reducing effort of breathing by placing in semi-Fowler’s position
● Use medication to sedate an irritable child
● Provide for rest and decrease environmental stimuli
○ Provide feedings every three hours to provide for adequate rest and allow the
infant to take the required amount within a 30 minute time frame. Feedings may
require additional calorie supplementation.
Improve tissue oxygenation and decrease oxygen consumption
● Supplemental cool humidified oxygen
● Oxygen hood, nasal cannula, face tent
○ Cool oxygen counteracts the drying effects of oxygen

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Acute Rheumatic Fever and Rheumatic Heart Disease
● Rheumatic fever
○ Delayed sequelae of group A streptococcal pharyngeal infection

● Rheumatic Fever Complications

○ Damage to heart valves - Usually develops 2-3 weeks after strep throat
○ If infection is left untreated it can lead to bacterial or fungi clumps that break off
and travel to the lungs, brain, kidneys, or other organs
○ Antibodies are formed in response to the organism, and lesions develop in the
heart and joints
○ Carditis – inflammation of the endocardium including the valves, myocardium,
and pericardium
○ Chorea – involuntary, purposeless, jerking movements of the legs, arms, and face
with speech impairment.
○ Erythema marginatum – classic maculopapular red rash with central clearing and
elevated edges. Usually on the trunk, painless
○ Subcutaneous nodules – usually in the wrist, elbows, and knees – painless.

● Treatment for Rheumatic Fever

○ Antibiotics (usually penicillin)
○ Anti-inflammatories

Kawasaki Disease
● Acute febrile illness that causes widespread systemic vasculitis. Inflammation of small
and medium-sized blood vessels. Unknown etiology but thought to result from an
infectious cause
○ It is a self-limiting syndrome but causes serious cardiovascular sequelae in up to
25% of affected children.
○ Creates coronary artery aneurysms → MI
○ Mostly affects children under the age of 5 – peak incidence during the toddler
years
○ More common in the winter and spring

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● Signs and Symptoms
○ For Kawasaki disease to be diagnosed in the child, a fever for more than 5 days
along with four of the principle must be met. (p. 1262; Box 42.12)
■ Conjunctival inflammation with no exudate
■ With red, dry, cracked lips; red, dry, “strawberry” tongue; and pharyngitis
■ Typically macular; it begins on the extremities, spreads to the trunk, and is
often pruritic (no vesicles or petechiae)
■ Erythema and edema of the palms and soles of the feet during the acute
phase; in the subacute phase peeling of the hands and feet
■ Usually unilateral, is characterized by nodes larger than 1.5 cm
○ Lab to confirm diagnosis
■ Anti–streptolysin O titer

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 ○ Three phases: acute febrile phase (7-14 days), subacute phase (10-24 days), and
convalescent phase (6-8 weeks)
○ During the subacute phase – arthritis (mostly in the large joints – knees, hips and
elbows), desquamation of the extremities, beginning with the digits and followed
by peeling off in sheets from the palms and soles
● Kawasaki Disease Treatment
○ IV gamma globulin (IG) - first 7 days to prevent coronary aneurysms
○ Aspirin therapy- anti-inflammatory to control fever and symptoms of
inflammation. After fever subsides – change to antiplatelet dose
○ Clopidogrel (Plavix), Enoxaprin (Lovenox) or Warfarin (Coumadin)
● Kawasaki Disease Nursing Interventions
○ Monitor child’s clinical status
■ Vital signs, rashes, I&Os
○ Institute measures to lower fever
■ Antipyretics, sponge baths, maintain sz precautions, give fluids child like
(popsicles,etc)
○ Monitor child for cardiac complication
■ Use cardiac monitor during acute and subacute phases; explain ECG &
echo to parents
○ Monitor for signs of bleeding due to aspirin therapy
○ Provide comfort measures
■ Oral hygiene, lips moist; keep stimulation to a minimum, helps with
itching
○ Promote child’s nutrition
○ Prevent contractures
■ Prevent contractures – stretching and passive range of motion exercises

Coarctation – pulses in the upper extremities are bounding and lower extremities are
weak and absent…. upper body is hot and bottom is cold
-Narrowing of aorta (High BP in upper extremities, low BP in lower extremities)
-S/S: dizziness, leg pain, heart pain, weakness
-Risk for aortic aneurysm and can lead to stroke

HF- dysrhythmias, don’t like to eat, only feed for 30mins

Aortic Stenosis – valve is too small, left ventricle swells (hypertrophic) trying to get through tiny
opening, asymptomatic
child stands for too long and faints, activity intolerance
Assess pulses – if aortic stenosis is severe may faint

Digoxin – don’t give if pulse is less than 90 in young children or 70 in older children –
know what it does for a kid –
Digoxin toxicity- halos and nausea and vomiting

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Kawasaki disease – Make body red and scan for heart issues, use cardiac monitor
-Treatment: gamma globin and aspirin – prevents aneurysm
-Signs/symptoms: conjunctival hyperemia, high fever, strawberry tongue, hands, and feet
swollen and peeling, pruritic rash that spreads
-Teaching for Kawasaki’s – only condition we can give aspirin for !!!

Know which cardiac defects are increased pulmonary blood flow defects and which are
decreased pulmonary blood flow defects

Patent Ductus Arteriosus PDA – administer prostaglandin E to keep hole open, what
does it sound like? Machinery like… lots of questions…. prostaglandin to open it using
IV and indomethacin to close it….
-S/S – edema, crackles, dyspnea, coughing
Patent Ductus Arteriosus – at top of heart
Arterial Septal defect- if small will close by 18 months, or sutured closed/patched
(dyspnea on exertion if not treated/corrected later in life)
Ventricular septal defect – same as PDA but at bottom of heart, most common, sutured
closed, patched, or spontaneous closure

Cardiac catheterization – monitor height and weight and how to care for them after
-Assess for dysrhythmias and bradycardia because hypotension = bleeding

Tetralogy Fallot – what are the four heart defects (Saunders)

-Priority in Saunders: Position, oxygen, morphine, IV fluids, and document
-Pulmonary stenosis
-Ventricular septal defect (VSD)
-Overriding aorta - aorta is position more central which takes blood from both
right and left.
-Right ventricular hypertrophy

Overriding aorta=O2 levels are low because the mixing of blood in

-Hypercynaotic episode – baby turns blue (knees to chest), give oxygen and morphine
and fluids

Rheumatic fever – caused by strep, give antibiotics and they get muscle spasms

Questions from Explore More- Cardiac

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Respiratory
Kids are very susceptible to dehydration

Auscultation:
● Crackles pneumonia
● Rhonchi- Bronchiolities
● Stridor- croup, foreign body
● Wheezing- asthma

Croup- Inflammation of upperway

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Mild Croup
S/s: barking cough
Treatment:
● Supportive care( airway clearance, use of cool air, steam from shower, open the
freezer and get cold air, popsicles)
● Tylenol for fever
Moderate Croup- includes stridor (bark cough) when upset
Treatment: Decadron/dexamethasone (1 dose) - steroid- Last about 72 hours

Severe Croup- audible stridor when breathing

Treatment: supportive care, provide steroids (takes 3-4 hours), provide racemic
epinephrine (nebulizer)

Education:
● Provide treatment as soon as possible to avoid complete closure of airway. If
airway completely closes, We will not be able to intubate them.
● Monitor for extra muscle retractions, and stridor

Practice Questions:

1. Wet crackling sounds in the lungs: Rales

2. A collapse or airless portions of the lungs: Atelectasis
3. Enlargement of terminal phalanx of fingers: clubbing (cystic fibrosis)
4. High-pitched : stridor
5. Increased respiratory rate: tachypnea
6. Oxygen deficiency: Hypoxia
7. High- pitched musical sound on expiration: wheezing
8. Blue-stinged: cyanosis
9. Low pitched snoring sound in lungs: Rhonchi (bronchiolitis)
10. Inward pulling of soft tissues with respirations: retractions

Which physical findings would be most concerned in an infant with respiratory distress?
● Tachypnea
● Mild retractions
● Wheezing
● Grunting - sign of respiratory failure

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A 5-year old is brought to the ED with a temperature of 99.5 (37.5C), a barky cough,
stridor, and hoarseness. Which nursing intervention should the nurse prepare for?
● Immediate IV placement
● REspiratory treatment of racemic epinephrine. Stridor- very concerning
● Tracheostomy set at the bedside
● Information the child’s parents about tonsillectomy

Which assessment is of greatest concern in a 15-month old?

● The child is lying down and has moderate retractions, low grade fever, and nasal
congestion
● The child is in the tripod position and has diminished breath sounds and a
muffled cough
● The child is sitting up and has coarse breath sounds, coughing, and fussiness
● The child is restless and crying, has bilateral wheezes, and is feeding poorly

Nephrotic Syndrome

Drug of choice for Nephrotic Syndrome

● Medications -Prednisone (to initiate remission) corticosteroids

What is the expected outcomes before discontinuing prednisolone for the

treatment of nephrotic syndrome?
● Administer the drug until the protein incrases in the urine
● Administer the drug until the child is free of proteinuria for 3 days
● The child has an increased appetite and weight loss
● The child is able to receive scheduled live virus vaccines

The common clinical manifestations exhibited in children with nephrotic syndrome

include edema, massive proteinuria and hypoalbuminemia
● True
● False

Foods that we would teach parents to avoid to provide to children with nephrotic
syndrome

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High sodium foods that they should avoid? Smoked meat, pickled food, processed

A 3-year old child with nephrotic syndrome is admitted to the pediatric floor, which only
has semi-private rooms. Which pediatric patient would be the most appropriate
roommate for the nephrotic syndrome child?
● A 2-year old recovering from varicella
● A 3-year old with pneumonia
● A 3-year old with a fracture femur -Age appropriate and no infection
● A 6-year old postoperative tonsillectomy

Which type of acid-base imbalance is most often seen in children with renal failure?
● Respiratory alkalosis
● Respiratory acidosis
● Metabolic alkalosis
● Metabolic acidosis- kidney’s inability to get rid of waste

The vaccines approved for a child with a kidney transplant are DTAP, IVP, MMR, and
varicella
● True
● False

The nurse is caring for a young child with pre-acute renal failure (ARF). Which of the
following is the most common cause for this type of ARF?
● Wilm’s tumor
● Heart failure- fluid overload
● Vesicoureteral reflux
● Contrast media diagnostic

Cardiac chapter- why do we have systemic edema? Heart cannot pump to the body so
Kidneys not perfusing well because the heart is not working well.
In pediatric cardiac disorders are not about right or left side heart failure but about path
and pressure.

Acute Glomerulonephritis

The clinical manifestations of children that are associated with Acute

Glomerulonephritis:
● A - Nervousness
● B - Dependant edema
● C - Periorbital edema
● D - Decreased urine output
● E - Hematuria
● F - Hypertension
● G - Low sodium

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 ● H - Low potassium

NSAIDS should not be administered to children with renal function problems as the
prostaglandin action can further decrease the glomerular filtration rate
● True
● False

Which treatment is not used for acute glomerulonephritis but for the treatment of the
original strep infection that was responsible for causing acute glomerulonephritis?
● NSAIDS
● Antihypertensives
● Diuretics
● Antibiotics

A child with acute glomerulonephritis is in the playroom of the hospital and experiences
blurred vision with a headache. Which action should be taken by the nurse?
● Check the urine to see if hematuria has increased
● Obtain a blood pressure
● Reassure the child and encourage bed rest until the headache improves
● Follow on serum electrolytes

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