CCC Nurs 235 - Pediatric & Maternity NursingFinal Study Guide

8/6/2019 CCC Nurs 235 - Pediatric & Maternity NursingFinal Study Guide

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EXAM6

NOTESChild 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 heartmuscle, scarring, cardiac calcification).S/S= ESR & C-reactive protein (shows inflammation), Fever (unresponsive to antibx, at least5 days), red & dry conjunctivae, inflamed oral mucosa (dry cracked lips, strawberrytongue), Edema (hands & feet, erythematous)Cardiac= coronary aneurysm (leading to MI), inflammation, ECG changes, LV fxn, mitralregurgitation

TX= dose IVIG w salicylate therapy, ASA-Cardiac Catheritization= catheter inserted into peripheral blood vessel (angiography= w contrast)

Two kinds:R sides venous= into RAL sided arterial= into aorta & LV

Yields info on:O2 sat in chambers of heart, pressure changesCO or SV (amt of blood pumped out LV to aorta w each contractionAnatomic abnormalities (obstruction)

RN Care:Mark/check pedal pulses, Temp, v/s (q15), dressing (bleeding), fluids for hydrationContraindication= diaper rashBleeding @ 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/hepaticcirculation) inferior vena cava RA Foramen Oval (or pulm art out duct art) LALV 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 closesabout 4th day (fibrin deposits... . murmur heard until it closes)-Cardiac Pressures


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-RA= 705%, 3-7 mmhg. Not oxygenated, low pressure-RV= 705%, 25/0 mmhg. Not oxygenated (no change from RA), in pressure since RV is a pump-PA= 705%, 25/10 mmhg. Still not oxygenated, no big pressure change.-LA= 973%, 5-10 mmhg. Oxygenated (blood has been to lungs), pressure er than R side of heartbut lower than ventricle pressure-LV= 973%, (O2 same, oxygenated) pressure 4x greater than RV

50-60 Preterm baby

65-80 Full term baby100/10 Normal child-Ao= 973%, 100/70. O2 same, pressure still high (sent out to perfuse body)

-Shunts/defectsShunt= blood flow takes abnormal pathway ( in pressure in heart, blood takes path of leastresistance)Cyanotic = (More Severe) Unoxygenated blood (hasn't been to lungs) gets out into systemcirculation. pulm flow

Acyanotic = oxygenated blood not getting out of heart/pulm into systemic circulation. pulmflow (= enlargement)

-Ventricular Septal Defect (VSD ) Acyanotic


3/13

-BF= RARVpulm artlungspulm veinLALVAbnormal opening in septum btwn LV & RV. er pressure in LV so blood flows path of leastresistance into RV (instead of out aorta into systemic circulation). Size of hole varies (50%of small ones close of own)Causes pressure in pulm art (due to excess blood vol.) and RV( poss hypertrophy) and O2sat in RV

TX=Small hole left to close on own.

Large hole= Suture or patch (will collect firbrin/clots an eventually close)Huge hole= PAB (Pulm Artery banding). amt of blood able to exit through pulm art(since extra blood is being shunted there) Goal of tx is to amt of blood going to pulmart. Surgery 3-4 yrs.S/s= recurrent resp infections (warning sign!!!) fatigue, dyspnea, murmur, HF later in life if unDX

-Atrial Septum Defect (ASD) Acyanotic

-BF= RARVpulm art lungs pulm vein LA

Abnormal opening btwn LA & RV. er pressure in LA so oxygenated blood follows path of leastresistance into RA.Causes= pressure in R side of heart (due to excess blood volume) and O2 sat in RA (70)due to mixing of blood.S/S= growth retardation/small for age, fatigue, dyspnea, murmur, HF (later in life if unDX)

Tx=requires surgery for larger holes/ severe s/s ( holes will not close on own). Survival wsurgery (2-4 yrs) @99%

-Patent Ductus Arteriosis (PDA) Acyanotic


4/13

-BF= RARV pulm art lungs pulm vienLA LV aortaDuctus Art. reamins open. Pressure in aorta is 4x in aorta than pulm art so blood followspath of least resistance back to pulm art (and to lungs).LA & LV enlarged (due to excess blood going into pulm circulation and back to L side of heart).Enlargement of L side

er O2 sat in pulm art (mixing of oxygenated blood thru patent duct art.)Rubella linked!!!

Tx= Indomethacin (prostaglandin inhibitor that closes small % of them). If not, simple surgery(3-6 yrs)

-Aortic Stenosis (AS) Acyanotic

-BF=RARVpulm art lungs pulm vien LALVNarrowing of aorta causes back up of blood. LV has to work harder to push blood throughnarrowing. CO (=less perfusion) Neonate mortality 10-20%S/S= faint pulses, hypotension, exercise intolerance


5/13

TX= balloon dilation, then aortic valvectomy or replacement (open heart surgery). 25%recurrence, poss aortic valve regurgitation.

-Coarctation of the Aorta (COA) Acyanotic

-BF= RARVpulm art lungs pulm vien LALVaortaNarrowing anywhere along aorta. es pressure proximal to narrowing. Blood backs up into Lside of heart (enlargement and pressure). DIFFERENT BP IN ARMS/LEGS IS A BIG SIGNBLACK BOX WARNING

BP= above narrowing (brain, bounding carotid)BP= below narrowing (lower body, weak/absent pedal or femoral pulses)

S/S= HA, epistaxis, poor lower circulation, mottling, DIFF BP IN LOWER AND UPPER EXT TX= graft, angioplasty w balloon. Surgery 3-5 yrs.

-Tetraology of Fallot (TOF) Cyanotic

BF= RARV (er pressure in RV (due to pulm stenosis) VSD allows unoxygenated BF from RV to LVAorta

-Most common cyanotic defect. Unoxygenated blood into circulation.-Tetra means "4":

1. Pulm Stenosis of valve. Congenital2. 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.)


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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

-Transposition of the Great Arteries Cyanotic

-BF=RARVAORTALALVPULM ART Not compatible with life!!!Aorta & pulm artery switched!!!!Unoxygenated blood into circulation.Need ASD or VSD for life. will allow for some mixing of o2 and non-o2 blood.S/S=cyanosis, dyspnea, polycythemia (thick blood= CVA), cardiomegaly

TX= (DX with US). no tx= 90% dead within 1 yearRashkind= enlarge existing ASDBlalock-Hanlen= make an ASDMustard Procedure=crisscross arteries by prosthetic means (? i think)

-Assessment for Congenital Heart DefectsRESP= recurrent resp infections , RR, retractions, gruntingFEEDING= pulls back (needs air), fussy, falls asleep, never gets enough to eat/hungryACTIVITY=restless (sign of hypoxia), lethargic, doesn't attend to environmentCOLOR=pale, color worsens in some positionsPOSITIONING= muscle tone, flaccid, hyper extends neck (for more o2)HR= (to circulate blood faster, greater perfusion)CRY=weak, muffled

-PreOP/PostOP CarePre op Post op-Prevent: fatigue, infection-adequate nutrition-prepare family for surgery-pt cannot have a currentinfection

-monitor: resp fxn, cardiac fxn, F&E (don'toverload=CHF)-Control metabolic rate (control fever.... esHR)-Neruo: PERRL, grips, reflex, LOC (perfusion of brain)Comfort: morphine, Dilaudid, turn q 2 hrs

-CHF (congestive heart failure)S/S= tachycardia, gallop, tachypnea, urine output (=edema), pulses, sweating, FTT (failureto thrive), exercise tolerance

Tx= NRG use, feed in small amounts & often), maintain Temp, o2, diuretics, DIGOXIN


7/13

-Digoxin (Lanoxin) (anitarrythmic, inotropic)Indication= HF, A-fib, A-flutterAction= Slows the HR (ventricular rate), makes the heart work more efficiently . Increasesforce of myocardial contraction.Administration:

-in MICROgrams, no mg's. Be careful!!-2 licensed RNs

-take apical pulse for 1 full minute60=adult70= kids90-110= infant/toddler

Side effects=fatigue, bradycardia, n/v, arrythmiasBLACK BOX WARNING= Hypokalemia enhances Digoxin effects, ing risk of digoxin toxicity.Hyperkalmeia diminishes digoxins effect. Monitor Potassium levelsclosely (3.5-5.5 mmol/L)BLACK BOX WARNING= therapuetic serum digoxin range= 0.8-2 mcg/L. Observe for s/stoxicity (bradycardia, n/v)BLACK BOX WARNING= Infants rarely get more than 1ml (50mcg or 0.05mg) in one dose.Have another RN check calculations.

-Rheumatic FeverInflammatory 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 uporgans), 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 proceduresCorticosteroids if inflammation in severeDigoxin

Tx of ANY sore throatRN 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 themSmall meals

Complications of Diabetes Mellitus: Preexisting andGestational-Production of insulin is absent or inadequate. Causes cell starvation (insulin is the "key" to getting

glucose into cells). P-In absence of glucose, cells break fats & proteins (leads to ketones in urine)-glucose has hypersomotic pull (expands blood vol, blood vol that already increased in pregnantwoman). Causes cellular dehydration (hence being thirsty with hyperglycemia)-In pregnancy, keep blood glucose


8/13

-No traveling recommended in 3rd trimester

-Pregnancy Adaptations with DiabetesTRIMESTER NORMAL PREEXISTING GESTATIONAL

1st Less insulin needed(pregnancy hormones insulin production)

Required Insulin dosage Required Insulindosage

2nd(begin)

Insulin resistance due tohormonal 'es (tolerance to glucose,hepatic stores)

Constantly monitor insulindose increments (needsconstantly ing)

@18-20 wks insulinrequirements > thanpre-pregnant needsGDM shows up (2ndtrmstr)

3rd()

Able to meet insulindemands

Double or quadrupleinsulin dose needed. Teammanagement

Produce less insulinthan needed

-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/insulinD and above= produce IUGR babies (due to poor placental perfusion)

-Normal Metabolic Changes in Pregnancy1st Trimester= in hormones (estrogen & progesterone) stimulate pancreas to make insulin. in tissue glucose stores happens & in hepatic glucose stores (can all causeHYPOglycemia).2nd and 3rd Trimester= Diabetogenic effect : in mom, hormones cause tolerance to glucose, resistance to insulin and hepatic glucose production (all ensures abundant glucose supplyfor fetus). HPL (human placental Lactogen) & other hormones tissue resistance toinsulin. In short, Diab. effect = insulin sensitivity.Birth= expulsion of placenta (3rd stage of pregnancy) causes abrupt of hormones. Momquickly regains prepregnancy insulin sensitivity (7-10 days w/o breast feeding)

-Fetal Effects From Diabetes & PregnancyGoal= euglycemia w/o vasular disease (placental compromise)Maternal Hyperglycemia-fetal hyperinsulinemia (producing lrg amts of insulin to deal with lrg

amts of glucose crossing placenta from mom)Macrosomia= insulin acts as a growth hormone. Baby is large w/ immature organs that havefat deposits. Monitor LS ratio, want 3.5:1 instead of 2:1 b/c lungs are immature. Risk forinjury/trauma at birth due to size.IUGR= if there is placental perfusion.Neural Tube defects= incidence if blood glucose not controlled at time of conception(MSAFP)

-Gestation Diabetes MellitusDX= usually in 2nd half of pregnancy, 18-20 weeks (due to 1st trimester in insulin demand...it masks it). Some manage with diet/exercise, others require insulin.Index Pregnancy= 1st pregnancy where they DX gestation diabetes.Management= Screen all women early (initial and 24 wk visit)

Goal= euglycemia & delivery when fetal lungs are mature and before complications.Utilize interdisciplinary team

Tests= 50g oral glucose test (1 hr glucose challenge or glucose tolerance test [GTT]).+>130-140

100g 3 hr GTT +>130-140HbA1c= Hemoglobin A1c is the portion of hemoglobin that binds with glucose (orbecomes "glycosylated). A % of them become saturated for the life of the RBC.

This test is a measure of glycemic control over time (previous 4-6 weeks)

-Assessment in Clinical Practice for DiabetesNORMAL PREEXISTING GDM


9/13

-HX & urine dipstick (lookingfor glucose and ketones) @office visits

-Whites Scale to ID vasculardisease-Urine dipstick (glucose &ketones) @ office visits

-Asses risk factors (family HX& maternal HX)-Urine dipstick (glucose &ketones) @ office visits

Routine 50g 1hr GTT @ 24wks

Assess diet, exercise, insulin(no 1hr GTT since we knowshe has DM)

50 g 1hr GTT is s/s before 24weeks

Possible reference for 100g3hr GTT (if 1hr GTT is +)

HbA1c, diet, exercise, insulinregulation (frequent es ininsulin need w pregnancy)

HbA1c & plan to reevaluate at6wk Post Partum visit (to seeif Mom returned toprepregnancy norms

-Target Blood Glucose Levels in PregnancyFasting Blood Glucose (FBG)= 60-105 mg/dL ac (before meals). Same for GDM1hr Post Prandial (after meal)=


10/13

Greatly reduced insulin needs Significantly reduced insulinneeds

35-55% have s/s DM in 5-15yrs

Metabolism normal in 3 wks(back to prepregnant state)

Need for insulin may bedelayed 24-72 hrs afterdelivery

Review= diet/exercise,normal weight, s/s hyper-hypoglycemia

Monitor glucose levels QID orPRN

Meal/exercise plan forlactation

Avoid oral contraception(chemically es body) Use

barrier methodFBS 1 day pp (reevaluate @6wks)

Pediatric Genitourinary DysfunctionBlack Box Warning-No fleets enema for Renal Failure= hyperphosphatemia-Automatic UTI eval= incontinence in a toilet rained child, strong smelling urine, frequency/urgency

-Wilm's TumorMost common renal tumor. Prognosis: stage 1&2= 90%; Mets= 50%Embryonal adenocarcoma= pt is born with it. Dx'ed in infancy or toddlerhoodUsually 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 properlyto filter), vomiting, abd pain, fever, hematuria, CA s/s= pallor, weight loss, lethargyDX Eval= family hX (cancer in general, congenital anomalies)

urinalysis =Hematuria24 hr= is it Wilms tumor or neuroblastoma? catecholamines = neuroblastoma

X-ray/scans= look for metsIVP= intravenous pilogram= contrast to see

TX= surgical removal with in 24 hrs (tumor is aggressive, mets quickly) Remove tumor andaffected tissue (lymph nodes)

Stage 1= confined to ONE kidney, resected. No mets.Stage 2= mets beyond kidney but all can be removedStage 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


11/13

Post op= Large pressure bandage (sedation or restraints?), suprapubic catheter until penishealsComplications= fistula, infection, hematuria, frequency, dysuria

Exstrophy of the BladderBorn with bladder outside of body (picked up in US, born c-section). Bladder seen as redseeping (urine) mass

Can effect joints (hip socket rotated posterolaterally)Female= labia separated, opening tiltedMale=inguinal hernia, undescended testicles, epospadias

TX= Goal= prevent or tx infection, avoid trauma, promote growth and development. Promotebonding (NICU)

Surgery= with in 48 hrs. Keep sterile and moist. Monitor fro fluid loss.1) Put baldder inside of abd cavity2)fix epospaidias3)fix other complications (reconstructions of ureters)

Complications= infection, hydronephrosis (urine backflow into kidneys, heptomegaly)Reflux= antibx, antispasmodics, analgesics, sedativePsychosocial= inadequate penis size, different looking gentialia, ? procreation, female rejection

CryptorchidismUndescended testicles. Absence of 1 or bothMore 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 (bloodvessels get wrapped around, cut off ... surgical emergency)

Tx= Serum testosterone/hormone therapyOrchidopexy= correct by age 2, simple surgery

Teaching= testicular exams later in life

UTICommon in male up to 4 mo's, females (short urethra...3/4 inch, 1 inche in adulthood)Don't= use bubblebath, tight nylon panties,Do= wipe front to back, pee before/after sexual intercourse, adequate urine output, frequentbladder emptyingUntx'ed= septicimiea and death

Repeated infections:Damage to bladder walls/ valves (vesicouretoral),Scarring/loss of renal tissuePyelonephritis= reflux of urine to kidneys (due to dilated ureters) causinginfection/inflammation

S/S=Infant= fever, vomiting, diarrhea, irritability, lethargy, poor feeding, poor weight gainChild= 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

Acute, Uncomplicated UTI (dx)UTI of an older child (schoolmate) 80% E. ColiS/S=urgency, frequency, uncomfortable, pain

TX= Trimethoprin (Septra), Amoxicillin (broad spectrum synthetic PCN), OR IMAmikacin (1 time dose)

Recurrent UTIInfection that occurs after previous one has been successfully tx'ed (urinalysis wasclean)

TX= place on prophylactic antibx (low dose) for years until child grows out of it

Complicated InfectionsChild=


12/13

Collecting Urine SpecimensPotty trained= midstream clean catch (like with adult)Baby= bag around meatus, check frequentlyStraight cath= possibility of contaminationSuprapubic Aspiration= ABSOLUTE STERILE specimen needed. Needle into abd cavityinto bladder.

Painful, topical anesthetic only. Done by MD

Vesicoureteral RefluxAbnormal backflow of urine from bladder, up ureters (and possibly into kidneys... High gradeVUR[pyelonephritis])29-50% following UTICan be from noncompliance or intolerance to antibx

Primary Reflux= Part of submucosal ureter is congenitally short ( part that tunnels intobladder)Secondary Reflux= ureter/valves damaged by chronic infection

Tx= Surgical Intervention= fix anatomic abnormalityLengthen 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 here1 stent from bladder. After inflammation goes does, urine will drain from here

Color= bright red (hematuria) then orange (pee and blood), then clear yellowAntibx (stents offer bacteria access to sterile warm environment)Pain relife & antispasmodics (just touching bag can cause spasm/pain in ureters)

Acute Poststreptoccocal Glomerulonephritis (AGN)Inflammation of the glomeruli of the kidneyStrep= if untx'ed will lead to 2 things= this and Rhuematic Fever

Strep Antibodies make anit body/antigen complex (made of proteins) that damagekidney

S/S= GFR, edema, hematuria & proteinuria (shouldn't be allowed past kidney) Pale due tolost rbc's

= puffy face, grade fever, dark amber urine, HTN (only w nephritis) 140's. 150'sDX=

Hematuria and protienuria (kidney not filtering properly)

BUN (evals kidney fxn, low= failure) and Creatinine (excreted by kidney, used as amarker of kidney fxn)ASO (measure for strep infection), ESR (shows inflammation)

Throat CultureRN Care

Fluid restriction (edema)Diet restriction to carbs and fat (NA and K might be restricted)Antihypertensives, diuretics, antibx,Diuresis in 1-3 weeks

D/C when:Normal weight and BP

Black Box WarningSuspect AGN with s/s of: Periorbital edema (parents reprot in am)

Loss of appetite, urinary output, tea colored urine, preceded by strep

Nephrotic SyndromeAlteration in renal fxn sue to glomerular injury. 90% idiopathic. Boys 2:1Defect in glom membrane allowing protein to leak out lowers colloid osmotic pressure fluidleaves vascular space for tissue edemaS/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)


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Hgb, Hct, Platelets, Specific Gravity (urine concentrated, full on protein)

TX=Bedrest with significant edemaSteriods 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.RNMinimal urine output of child= 1ml/kg/hrDiuretics, daily weight (marker of fluid status)Prevent infection (steroids mask s/s of infection)

(AGN) NEPHRITIS NEPHROSIS+ strep No strep+ HTN No BP

Pronounced Hematuria (someProteinuria)

Pronounced Proteinuria (4+)

Happens at younger age; Boys

Nephrosis Evaluation

Normal urine SG (was concentrated due to albumin [protein] loss); clear and yellow in colorNormal ElectrolytesNormal Weight (diuresis of edema)Balanced I&OLack of proteinuria

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CCC Nurs 235 - Pediatric & Maternity NursingFinal Study Guide