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NOTES
Child with
Cardiovascular Dysfunction
-Kawasaki Disease= acute systemic vasculitis of unknown cause
(widespread inflammation)
Untx'ed= 20-25% develop cardiac sequelae (damage to coronary blood vessels and heart
muscle, scarring, cardiac calcification).
S/S=↑ ESR & C-reactive protein (shows inflammation), Fever (unresponsive to antibx, at least
5 days), red & dry conjunctivae, inflamed oral mucosa (dry cracked lips, strawberry
tongue), Edema (hands & feet, erythematous)
Cardiac= coronary aneurysm (leading to MI), inflammation, ECG changes, ↓LV fxn, mitral
regurgitation
TX= ↑dose IVIG w salicylate therapy, ASA
-Cardiac Catheritization= catheter inserted into peripheral blood vessel (angiography= w contrast)
Two kinds:
R sides venous= into RA
L sided arterial= into aorta & LV
Yields info on:
O2 sat in chambers of heart, pressure changes
CO or SV (amt of blood pumped out LV to aorta w each contraction
Anatomic abnormalities (obstruction)
RN Care:
Mark/check pedal pulses, Temp, v/s (q15), dressing (bleeding), fluids for hydration
Contraindication= diaper rash
Bleeding @ site= direct continuous pressure 2.5 cm above vessel puncture ←BLACK
BOX WARNING
-Fetal Circulation
BF (blood flow)= Oxygenated blood in thru placenta→ umbilical vein→ liver (some to portal/hepatic
circulation)→ inferior vena cava→ RA→ Foramen Oval (or pulm art out duct art)→ LA→LV→ aorta.
-Small amount goes to lungs (some of that blood diverted by ductus arteriosis)
-Post natal= clamping of cord ↑ systemic circulation, ↑ pressure closes foramen ovale. Duct art closes
about 4th day (fibrin deposits.... murmur heard until it closes)
-Cardiac Pressures
-RA= 70±5%, 3-7 mmhg. Not oxygenated, low pressure
-RV= 70±5%, 25/0 mmhg. Not oxygenated (no change from RA), ↑ in pressure since RV is a pump
-PA= 70±5%, 25/10 mmhg. Still not oxygenated, no big pressure change.
-LA= 97±3%, 5-10 mmhg. Oxygenated (blood has been to lungs), pressure ↑er than R side of heart
but lower than ventricle pressure
-LV= 97±3%, (O2 same, oxygenated) pressure 4x greater than RV
50-60 Preterm baby
65-80 Full term baby
100/10 Normal child
-Ao= 97±3%, 100/70. O2 same, pressure still high (sent out to perfuse body)
-Shunts/defects
Shunt= blood flow takes abnormal pathway (∆ in pressure in heart, blood takes path of least
resistance)
Cyanotic= (More Severe) Unoxygenated blood (hasn't been to lungs) gets out into system
circulation. ↓pulm flow
Acyanotic= oxygenated blood not getting out of heart/pulm into systemic circulation. ↑ pulm
flow (= enlargement)
BF= RA→RV (↑er pressure in RV (due to pulm stenosis)→ VSD allows unoxygenated BF from RV to LV→
Aorta
-Most common cyanotic defect. Unoxygenated blood into circulation.
-Tetra means "4":
1. Pulm Stenosis of valve. Congenital
2. Aorta moved over towards septum (overwriting aorta). Congenital.
3. VSD (ventricular septal defect). Allows mixing of o2 and non-o2 blood. Congenital.
4. #1-3 leads to RV hypertrophy (enlargement due to excessive blood vol.)
S/S=paraoxymal dyspnea (diff breathing comes and goes), clubbing, squatting, growth retardation,
polycythemia (body tries to compensate for ↓blood o2.... leads to thickened blood= poss CVA),
murmur might not be picked up for 6 wks. Baby might have altered LOC.... leads MD to think
"cardiac workup"
Tx= close VSD, resect pulm artery
-PreOP/PostOP Care
Pre op Post op
-Prevent: fatigue, infection -monitor: resp fxn, cardiac fxn, F&E (don't
-adequate nutrition overload=CHF)
-prepare family for surgery -Control metabolic rate (control fever.... ↑es
-pt cannot have a current HR)
infection -Neruo: PERRL, grips, reflex, LOC (perfusion of
brain)
Comfort: morphine, Dilaudid, turn q 2 hrs
-Rheumatic Fever
Inflammatory Disease. Affects collagen tissue (joints, heart, adb cavity)
S/S= child has untreated strep infection (up to 6 weeks prior). Can lead to rheumatic fever
↑ fever, sore nodules (on joints, reoccurring), adb pain (collagen tissue hold up
organs), erythema (rash on chest/abd), arthritis in joints (migrates around joints)
Cardiac= Valves= incompetent, regurgitating, pericarditis.
Chorea= pt has mood swings, coordination off
DX= ↑ESR and C-reactive protein (indicators of inflammation)
↑WBC (from prev strep infection)
↑ASO (measures strep antibodies)
Cardtitis=cardiac enlargement= seen in x-ray. Aschoff bodies= nodules on heart
(valves), Ekg= prolonged PR interval
TX=
Recurrence= PCN for life prophylactic ally or before procedures
Corticosteroids if inflammation in severe
Digoxin
Tx of ANY sore throat
RN care=
Bed rest w cardiac evolvement (change position, no PNA or bed sores)
Chorea= be patient, slow down for them
Take pulse for 60 seconds
Joint pain= be gentle moving them
Small meals
-White's Scale
-Guide to classification of perinatal diabetes (method of classifying diabetes in pregnancy)
-alphabetical scale:
A-C= preexisting & gestational diabetes. Controlled w diet/exercise/insulin
D and above= produce IUGR babies (due to poor placental perfusion)
-Wilm's Tumor
Most common renal tumor. Prognosis: stage 1&2= 90%; Mets= 50%
Embryonal adenocarcoma= pt is born with it. Dx'ed in infancy or toddlerhood
Usually unilateral (favors LEFT kidney)
Once confirmed, do not palpate. Might break tumor apart ("seed" abd cavity with tumor cells)
S/S= firm smooth palapable mass (often found by parents), HTN (kidneys not working properly
to filter), vomiting, abd pain, fever, hematuria, CA s/s= pallor, weight loss, lethargy
DX Eval= family hX (cancer in general, congenital anomalies)
urinalysis =Hematuria
24 hr= is it Wilms tumor or neuroblastoma? ↑ catecholamines = neuroblastoma
X-ray/scans= look for mets
IVP= intravenous pilogram= contrast to see
TX= surgical removal with in 24 hrs (tumor is aggressive, mets quickly) Remove tumor and
affected tissue (lymph nodes)
Stage 1= confined to ONE kidney, resected. No mets.
Stage 2= mets beyond kidney but all can be removed
Stage 3= mets confined to abdominal cavity, cannot remove all
Stage 4= mets elsewhere in body (lungs, liver, bone, brain)
Stage 5= bilateral kidney involvement (transplant necessary)
Radiation= not <18 mo's age in Stage 1
Chemo= vincristine (n/v, hair loss, constipation[give colace])
RN= Palpate to find tumor, then hands off. Prevent rupture. Pre & Post op teaching
Post op= v/s, BP, I&O (intra-abdominal hemorrhage), inspiromter (prevent PNA),
intestinal obstruction (due to handling during surgery), adjunct thereapy (chemo,
radiation on 2nd or 3rd day)
Hypospadias
Urethral opens below meatus (urethra folds fail to close) (epospadias= ABOVE meatus,
less common)
Can be accompanied by= undescended testicles, inguinal hernia, Chordee (fibrous band cut in
surgery, curves penis)
Family HX (don't circumsize, might need tissue when surgically fixing)
TX= Goal= normalize appearance/fxn
Create opening in correct place. Fix Chordee
6-18 mo's (before child realizes they are "not normal")
Post op= Large pressure bandage (sedation or restraints?), suprapubic catheter until penis
heals
Complications= fistula, infection, hematuria, frequency, dysuria
Cryptorchidism
Undescended testicles. Absence of 1 or both
More prevalent in premies (descend later in life). Full term= 3-4%, Preterm= 17%
Palpable vs impalpable= US if cannot be found by palpation.
Un tx'ed= infertility, ↑ risk for testicular cancer, tumors, hernia, testicular torsion (blood
vessels get wrapped around, cut off ... surgical emergency)
Tx= Serum testosterone/hormone therapy
Orchidopexy= correct by age 2, simple surgery
Teaching= testicular exams later in life
UTI
Common in male up to 4 mo's, females (short urethra...3/4 inch, 1½ inche in adulthood)
Don't= use bubblebath, tight nylon panties,
Do= wipe front to back, pee before/after sexual intercourse, adequate urine output, frequent
bladder emptying
Untx'ed= septicimiea and death
Repeated infections:
Damage to bladder walls/ valves (vesicouretoral),
Scarring/loss of renal tissue
Pyelonephritis= reflux of urine to kidneys (due to dilated ureters) causing
infection/inflammation
S/S=
Infant= fever, vomiting, diarrhea, irritability, lethargy, poor feeding, poor weight gain
Child= dysuria, urgency, fever, adb pain, enuresis
DX= Us (anatomical problem?)
Cystourethrogram= see the system in action, shows reflux
Goal of TX= cure existing infection, identify/correct predisposing factors, prevent recurrence
Complicated Infections
Child= <3 yrs, Male, Febrile. E. Coli, Proteus, Klebsialla Pseudomonas
TX= IV meds for at least 48 hrs (with 2 antibx)
Collecting Urine Specimens
Potty trained= midstream clean catch (like with adult)
Baby= bag around meatus, check frequently
Straight cath= possibility of contamination
Suprapubic Aspiration= ABSOLUTE STERILE specimen needed. Needle into abd cavity
into bladder.
Painful, topical anesthetic only. Done by MD
Vesicoureteral Reflux
Abnormal backflow of urine from bladder, up ureters (and possibly into kidneys... High grade
VUR[pyelonephritis])
29-50% following UTI
Can be from noncompliance or intolerance to antibx
Primary Reflux= Part of submucosal ureter is congenitally short ( part that tunnels into
bladder)
Secondary Reflux= ureter/valves damaged by chronic infection
Tx= Surgical Intervention= fix anatomic abnormality
Lengthen submucosal segment, move site where ureter tunnels into bladder
Post-op=3 tubes:
2 stents, 1 for each ureter. First 48-72 hrs urine will drain from here
1 stent from bladder. After inflammation goes does, urine will drain from here
Color= bright red (hematuria) then orange (pee and blood), then clear yellow
Antibx (stents offer bacteria access to sterile warm environment)
Pain relife & antispasmodics (just touching bag can cause spasm/pain in ureters)
Nephrotic Syndrome
Alteration in renal fxn sue to glomerular injury. 90% idiopathic. Boys 2:1
Defect in glom membrane allowing protein to leak out→ lowers colloid osmotic pressure→ fluid
leaves vascular space for tissue→ edema
S/S= swollen eyes and abd (ascites),
DX=
Urinalysis (4+ protienurea), ↓ Albumin (it's a protein.... lost in urine)
Creatinine Clearance (excreted by kidney, used as a marker of kidney fxn)
Serum Cholesterol ↑
Na↓(due to water)
↑Hgb, Hct, Platelets, Specific Gravity (urine concentrated, full on protein)
TX=
Bedrest with significant edema
Steriods 3-4 x daily (prednisone with food)
Diuresis on own in 6-14 days
Cytoxin= used if steroids don't work. Chemo drug... will suppress bone marrow.
RN
Minimal urine output of child= 1ml/kg/hr
Diuretics, daily weight (marker of fluid status)
Prevent infection (steroids mask s/s of infection)
Nephrosis Evaluation
Normal urine SG (was concentrated due to albumin [protein] loss); clear and yellow in color
Normal Electrolytes
Normal Weight (diuresis of edema)
Balanced I&O
Lack of proteinuria