Pediatric Test 2

Cardiac Topics

Cyanotic Heart Defect Spironolactone

Acyanotic Heart Defect Digoxin
VSD Cardiac Catheterization
Tetrology of Fallot Cardiac Patient Teaching
Congestive Heart Failure Medication for Heart Transplant
Pulmonary Artery Hypertension Ineffective Endocarditis
Rheumatic Fever

- Cyanotic Heart Defect: defects that cause decreased pulmonary blood flow
o Defect that obstructs the pulmonary blood flow to the lungs or any
embryologic failure that permits no connection of the right sided blood
flow to the lungs decrease pulmonary blood flow. This results in little or
no blood reaching the lungs to get oxygenated.
o If an atrial or ventricular septal opening exists between the left and right
side of the heart, right sided pressures exceed those on the left, resulting in
RIGH LEFT shunting. Evidence of cyanosis is a classic sign of
decreased pulmonary blood flow.
o The kidneys produce the erythropoietin hormone that stimulates the bone
marrow to produce more RBC (Polycythemia) this can lead to thrombosis
o Signs and Symptoms:
 Cyanosis and CHF
 May have seizures due to hypoxia; fainting; confusion
 Marked exercise intolerance (SQUATTING helps to decrease
respiratory distress)
 Small stature
 FTT
 Difficulty eating
 Tachycardia
 Dyspnea
 Hypotonia
 Clubbing
 Frequent UTI
 Faint pulses
 Murmur

o Tetrology of Fallot
 Definition: a heart defect that decreases pulmonary blood flow.
There is an elevated pressure in the right side of the heart causing
RIGHT  LEFT shunt of blood. It is a combination of four
defects:
• Pulmonic stenosis
 • Right ventricular hypertrophy
• Ventricular septal Defect (VSD)
• Overriding of the aorta
 Diagnostic:
• A chest radiograph shows the boot shape heart due to the
large right ventricular, decreased pulmonary vascular
markings, and a prominent aorta.
• ECG shows right ventricular hypertrophy
 Clinical Therapy:
• Knee-chest position
• Managemen of hypercyanotic epidsodes includes placing
the infant in this position
• Calming the child
• Giving oxygen
• Administer MORPHINE and PROPANOLOL through IV
• Repair is often performed before 6 months of age when the
infant has a hypercyanotic episode

- Acyanotic Heart Defect: congenital heart defects that increase pulmonary blood
flow
o The most common congenital heart defect that results from a connection
between the left and right side of the heart and allows blood to flow from
LEFT  RIGHT and increases the amount of blood that needs to be
pumped to the lungs.
o As the lungs attempt to accommodate the increased pulmonary blood
flow, the infant’s heart rate and respiratory rate are increased
o Signs and Symptoms:
 CHF
 Dyspnea
 Tachypnea
 Intercostals retractions
 Periorbital edema

o Ventricular Septal Ductus (VSD): an opening in the ventricular septum

results in increased pulmonary blood flow. Blood is shunted from the left
ventricle straight into the pulmonary artery
 Signs and Symptoms:
• Tachypnea
• Dyspnea
• Poor growth
• Reduced fluid intake
• CHF
• Increased upper respiratory infections
• Pulmonary HTN
  Treatment:
• Surgery, however most small VSDs close with in 6 months

- Congestive Heart Failure

o Definition: a disorder of circulation in which cardiac output is inadequate
to support the body’s circulatory and metabolic needs. The most common
causes of CHF in infants are heart chamber and vessel pressures as well as
blood volume overloads associated with congenital heart defects.
o Some defects allow blood to flow from the left side of the heart to the
right so that extra blood must be pumped to the pulmonary system rather
than through the aorta when the left ventricle contracts.
 This overloads the pulmonary system and can lead to pulmonary
hypertension
• Vasoconstriction in pulmonary capillary bed right ventricle
has to work harder to pump into the lungs
o Hypertrophy of right side
o Engorged liver (full of fluid)
o JVD
o Obstructive congenital defects restrict the flow of blood so the heart
hypertrophies to work harder to force blood through these structures.
 This increases cardiac output initially, but eventually the
hypertrophied muscle becomes ineffective
• Failure eventually becomes bilateral
o As a result organs do not receive adequate oxygenation. Blood pressure
becomes decreased and blood now supplies only the vital organs. This
tells the body that to pull all blood flow from the lower extremities to
supply the vital organs. As a result, there is a decrease in circulatory flow
which tells the body to start that Renin Angiotensin Syndrome (retention
of Na and H2O)

o Clinical Manifestations:
 Impaired Manifestations:
• TACHYCARDIA
• Gallop Rhythm
• Diaphoresis
• Poor Perfusion
 Pulmonary Congestion:
• Tachypnea
• Mild cyanosis
• Dyspnea
• Pulmonary Edema
o Orthopnea
o Wheezing
 o Cough
• Hoarsness
• Gasping and Grunting
• Developmental Delays
 Systemic Venous Congestion:
• Hepatomegaly
o Enlarged Liver
• Edema
o Weight Gain
o Ascites
o Pleural Effusion
o Distended Neck and Peripheral Veins
o Assessment:
 Early Signs:
• TACHYCARDIA
• Tachypnea
• Profuse scalp sweating (Infants)
• Fatigue
• Irritability
• Sudden weight gain
• Resp. distress
 In Infants:
• CHF can be subtle
• Good assessment skills are a must
• Tires easily, especially during feedings
• Initial weight loss
• Diaphoresis, irritability, frequent infection
 In Children:
• Exercise intolerance
• Dyspnea
• Abdominal pain or distention
• Peripheral edema
 Assessment of Progressive disease:
• TACHYCARDIA
• Tachypnea
• Pallor or cyanosis
• Cough
• Crackles
• FV overload
• Periorbital and facial edema
• JVD
• Hepatomegaly
• Ascites
 • Increased weight gain
• Bounding pulses
• Edema of dependent body parts

o Nursing Interventions:
 Decrease cardiac demands
 Reduce resp. distress
 support child and family

o Therapeutic Management of CHF:

 Improve Cardiac Function:
• Digoxin
• Ace Inhibitors
o Catopril
o Enalapril
 Remove accumulated fluid and sodium
• Lasix
 Decrease cardiac demands
 Improve tissue oxygenation

o Medication Therapy:
 Positive inotropic effect and afterload reducing agents
• Digitalis
o Digoxin:
 Administer it everyday at the same time
with or w/o food
 Check apical pulse for full minute to note
bradycardia
 Check potassium levels if diuretics are
loosed
• Low K can increase the effects of
digoxin
 Observe for toxicity
• Tachycardia
o Young children
• Bradycardia
o Older children
• N/V
• Anorexia
• Dizziness
• Headache
• Weakness
• Fatigue
 • Arrhythmia
 Therapeutic Levels:
• 1.1 – 1.7 ng/mL
o ACE inhibitors (Angiotensin converting ezyme
inhibitors)
 Lisinopril
o Beta Blockers:
 Indural (propanolol)
o Diuretics:
 Lasix
 HCThiazide
 Aldactone (Spironolactone)
• Potassium sparing

o Supportive Treatment:
 Oxygen
 Fluids as indicated (cautious in CHF patients)
 Increased calories or concentrated formula
 Airway support/management
 Rest and spacing of activity/rest periods

o Surgical Treatment:
 Cardiac Catheterization:
• An outpatient procedure
• Assessment Preoperatively
o Childs vital signs
o Hematocrit and hemoglobin
o Capillary refill
o Skin temperature
o Strength of the pedal and popliteal pulse
 Ensures comparison for pre and post
surgical intervention
• Assessment Postoperatively:
o Monitor the child for potential complications such
as:
 Arrhythmia
 Bleeding
 Hematoma development
 Thrombus formation
 Infection
• No bleeding should occur at the cath site
• Vital Signs are done Q 15 minutes for 1 hours includes:
o Perfusion of the lower extremities:
  Pedal and popliteal pulses
 Skin temp
 Color
 Capillary refill
 Sensation
o Pressure dressing
• Monitor I/O because dye may cause diuresis
• Ileofemoral aretery injury is more common in newborns
and young infants after catheterization

- Medication for Heart Transplant

o Triple immunosuppression regimen:
 Tacrolimus or Cyclosporin A
 Azathioprine
 Corticosteroids
• High doses of IV steroids are used to treat episodes of acute
rejection

- Pulmonary Artery Hypertension:

o An increase pulmonary blood flow, pulmonary vascular resistance
develops. The pulmonary vascular bed compensates to reduce this
excessive pulmonary blood flow by vasoconstricting. This leads to right
to left shunting of blood (cyanotic)
o Clinical Manifestations:
 Hypoxemia
 Acidosis
 Tachypnea
 Cyanosis
 Retractions
 Fatigue
 Difficult feeding
 Weight loss
 F&E imbalance
 Older children:
• Exertional dyspnea
• Chest pain
• Syncope
o Collaborative Care:
 Surgery to correct an obstructive lesion or close a defect
 Noncardiac conditions involves:
• Bronchodilators
• Antibiotics
• Corticosteroids
• Low flow oxygen
  Short term nitric oxide therapy
o Nursing Management:
 Promoting rest for oxygen conservation
 Monitoring I/O
 Administering medication and oxygenation
 Exercise should be tailored to avoid dyspnea
 Give parents needed support and information about their child

- Inefective Endocarditis:
o An inflammation of the lining, valves, and arterial vessels of the heart
caused by bacterial, enterococci, and fungal infections.
o Infection may occur due to:
 Invasion of organism into the bloodstream during dental work or
surgery and lodges on damaged or abnormal endocardial tissue.
 Children with congenital heart disease, a high velocity or turbulent
blood flow can injure the endocardium.
 Indwelling catheters positioned in the right side of the heart also
damage the endocardium or valve endothelium
o Clinical Manifestations:
 Prolonged low grade fever
 Fatigue
 Weakness
 Weight loss
 Joint and muscle aches
 Diaphoresis
 New or changing murmur
 CHF
 Decreased oxygenation saturation level
 Dyspnea
 Hematuria
 Petechiae
 Splenomegaly
 Children w/ indwelling catheters may initially have pulmonary
symptoms or signs related to septic pulmonary embolism
 Newborns have variable nonspecific signs such as:
• Feeding difficulties
• Respiratory distress
• Tachycardia
o Diagnostic Procedures:
 The Duke Criteria
o Clinical Therapy:
 Administering antibiotics by way of IV for 2-8 weeks:
• Penicillin G
 • Ampicillin
• Vancomycin
• Nafcillin
• Gentamicin
 Surgery to replace a valve
o Nursing Interventions:
 Respiratory and Cardiovascular status
 Vital signs
 Oxygen saturation
 LOC as congestive heart failure and embolism may occur
 Child will be placed on a cardiac monitor and pulse oximeter
 Teach parents to ask for prophylaxis specifically prior to
procedures:
• Tonsillectomy or adenoidectomy
• Bronchoscopy
• Surgery on the respiratory, GI, and GU systems
 Children at moderate to sever risk for ineffective endocarditis
should restrain fro
• Body piercing
o Nose
o Tongue
o nipple
• Tattoos
 Keep invasive procedures to a minimum
 Use careful aseptic technique in performing:
• Venipunctures
• Urinary catheterizations

- Rheumatic Fever:
o An inflammatory connective tissue disorder that follows an initial
infection by some strains of group A beta hemolytic streptococci. This
disorder effects the heart, joints, brain, and skin tissues.

o Clinical Manifestations:
 1 – 3 weeks after an untreated streptococcal infection, the hallmark
signs of rheumatic fever may occur.
• Carditis:
o Aschoff bodies (hemorrhagic bullous lesions)
develop in the connective tissue of the heart.
Murmurs of the mitral and aortic can be heard
• Arthritis:
o Childs joints become inflamed and painful. The
large joints are more commonly affected with pain,
 swelling, tenderness, erythema, and heat. May
migrate from join – joint (polyarthritis)
• Subcutaneous nodules may be palpable near joints
• Erythema Marginatum:
o A skin rash with pink macules and blanching in the
middle of the lesions, is infrequently seen. It is seen
on the trunk and proximal extremities, but not on
the face.
• Sydenham Chorea:
o Aimless movements of the extremities and facial
grimacing.
o Diagnostic Procedures:
 Clinical signs
 Lab Testing:
• Antistreptolysin-O (ASLO) titer: to detect previous
streptococcal infection.
o Clinical Therapy:
 Antibiotics:
• Penicillin
• Sulfadiazine
• Erythromycin
 Aspirin
• Traditional anti-inflammatory medication prescribed for 3-
4 weeks, or longer if carditis is present. Serum levels are
administered can cause problems
 Steroids
 Genitourinary Topics

Hypospadias Renal Failure

Obstructive Uropathy Drug to suppress Kidney Transplant Rejection
UTI Hemodialysis
Drug to treat Enuresis Bactrim
Nephrotic Syndrome Pyloromyotomy
Glomerulonephritis Prednisone administration

Hypospadias
o urethral meatus located on the ventral surface of the penile shaft

o Diagnostics
o Ultrasound (prenatally)
o Physical exam (at birth)

 Surgical repair (usually same day surgery)

 Family teaching
o Double-diapering technique
o Activity limitations
o Hydration
o Medication
o Signs of infection
o Color of urine
Obstructive Uropathy

o Structural/functional anomalies that alter normal urine outflow

o Pressure caused by urine backflow can result in hydronephrosis
o Physiologic changes caused by hydronephrosis
 Glomerular filtration stops when the pressure in the kidney pelvis =
the filtration pressure in the glomerular capillaries
 Metabolic acidosis (the impaired distal nephrons are unable to secrete
hydrogen ions)
 Kidney unable to concentrate urine
 Urinary stasis
 Restricted urinary outflow

Clinical manifestations of congenital obstructive lesions

Obstruction Site Obstructive Lesion Clinical Manifestations
Infants children
Ureteropelvic valve Ureteropelvic junction Abdominal mass Hematuria
obstruction Hypertension Pain
UTI Intermittent N/V
Stenosis @ Ureterovesicular junction UTI
ureterovesicular obstruction Hematuria
junction Pain
Abdominal Mass
Enuresis
Posterior urethral Posterior urethral valves Abdominal mass Urinary frequency
valve Distended bladder Incontinence
Poor urinary stream
UTI
Polyuria
Sepsis
Failure to thrive
Decreased specific gravity
Increased creatinine level

 Prevention of kidney damage and the decline of renal function are crucial!!

 Surgical correction or diversion may be necessary to decrease the pressure within

the urinary collecting system

Urinary Tract Infection:

 Clinical Manifestations and Clinical Therapy for UTI
Type of UTI Clinical Manifestations Clinical Therapy
Lower UTI – cystitis Frequency  5 – 7 day course of trimethoprim
Dysuria or sulfamethoxazole or Antibiotic
Urgency for specific organism
Enuresis  Encourage fluids
Strong-smelling urine  Analgesic (Tylenol or pyridium)
Upper UTI – High fever  Rehydration
Pyelonephritis Chills  Antipyretics
Abdominal pain  IV antibiotics to oral antibiotics
Flank pain for 7 – 10 days
Persistent vomiting
Moderate to severe
dehydration
 Common Nursing Diagnoses for the child with UTI
o Altered urinary elimination
o Risk for altered growth
o Urinary retention
o Risk for ineffective management of therapeutic regimen
Risk for fluid volume deficit
Renal Disorders
o Nephrotic Syndrome
 Congenital
 Primary
• Type of primary – minimal change nephritic syndrome
(MCNS)
• Most common form
 Secondary
o Acute Poststreptococcal Glomerulonephritis (APSGN)
 Most often a response to group A beta-hemolytic streptococcal
infection of the skin or pharynx
 More common in boys

APSGN vs Nephrotic Syndrome

Assessment Factor APSGN Nephrotic Syndrome
Edema
Hematuria
Proteinuria
Blood Pressure
Anorexia
Pain, discomfort
Fatigue, activity intolerance
Serum albumin/protein
levels
Serum lipid levels
Serum electrolyte levels
Hemoglobin and hematocrit
Serum creatinine and BUN
Serum streptococcal
antibody titers
Age at onset

Nursing Intervention APSGN Nephrotic Syndrome

Intake and Output

Weight Measurement

Diet

Fluids

Positioning

Skin Care

Medications

Renal Failure
Acute Renal Failure (ARF) vs Chronic Renal Failure (CRF)
Types of Renal Failure Clinical Manifestations Diagnostics
ARF Gross hematuria Urinalysis
Headache  Low pH
Edema  Osmolarity
Severe hypertension  Specific gravity
Lethargy  + protein
N/V
 Oliguria Blood Chemistry
 Elevated K+
 Na+ varies
 Low Ca+
 High Phosphorous
 BUN increased
 Creatinine increased
 Low pH
o
CRF Fatigue Serum electrolyte
Malaise Phosphate
Poor appetite BUN
Prolonged,unexplained N/V Creatinine levels
Failure to thrive pH
Poor school performance
Secondary enuresis
Chronic anemia
Hypertension
Unusual bone disease

- Drugs to treat Enuresis:

o Desmopressin Acetate (DDAVP):
 A vasopressin with an anti-diuretic effect. It reduces urine
production for 8-12 hours. It may be administered by way of nasal
spray or tablet. Used for enuresis
 It is often given to kids for sleep overs and camping
 Parents should monitor Blood Pressure and Weight
o Oxybutynin (Ditropan):
 An anticholinergic used for enuresis that relaxes smooth muscle of
the bladder that promotes bladder tonicity (capacity). It is given in
the form of oral administration and extended release tablets.
 Teach parents to monitor effects.
 It may also cause dry mouth
o Imipramine (Tofranil):
 A Trycyclic Antidepressant useful in nocturnal enuresis due to
anticholinergic activity and nervous system stimulation. This
helps with earl arousal.
• Monitor for mood changes and excessive fatigue
• Administer 1 hour before bedtime and with food
• Weigh child 2X/weekly and monitor for edema
• OTC drugs are avoided

- Drugs given to suppress rejection of kidney transplant:

 o After transplantation, the child receives immunosuppressive medications
such as:
 Corticosteroids
 Azathiprine
 Cyclosporine
 Antilymphocyte antibodies

- Hemodialysis:
o Requires creation of a vascular access and special dialysis equipment
o Best suited for children who can be brought to facility 3x/week for 4-6
hours
o Achieves rapid correction of fluid and electrolyte abnormalities

GI Topics

Abdominal distention Gastroesophageal Reflux

Pylorotomy Hirschsprung’s Disease
Transesophageal Fistula Gastroenteritis
Ostomy Care Appendectomy (Pain Management)
Pyloric Stenosis Celiac Disease
Rotavirus

Acute Gastrointestinal Disorders: (Gastrointeritis)

Rotavirus:
o Common cause of diarrhea in children
 Found in the (nursery setting )
o It is characterized by 2 days of fever and vomiting, followed by 5-7 days
of watery (explosive) diarrhea
o Most incidents occur with the child presenting to the ER with a diagnosis
of dehydration.
 They may also have electrolyte imbalances as well as fluid
imbalances.
- Assessment of Rotavirus and Clostridium difficile (C. difficile):
o Nursing History:
  Assess possible exposure
 Onset
 Descriptions of symptoms and length
 Other events: weight loss, stool patterns, eating patterns
 Reports of fatigue and malaise
o Obtain baseline Height and Weight

o Nutrition:
 Maintain nutrition with fluids and this is determined by weights

o Signs and Symptoms of dehydration:

 Dry mucous membranes
 Poor skin turgor with paleness
 Tachycardia
 Sunken fontanels
 Decreased urine output and concentrated
• Specific Gravity: High
 Thirsty
 Blood Pressure: decreased b/c of volume decrease
 Decreased potassium

- Interventions for Rotavirus and C. difficile:

o Obtain stool sample
 Occult blood test
o Monitor I/O’s
 urine and stool
o Obtain daily weights
o Avoid rectal temperatures
 VS q 4 hours
o Administer IV fluids as ordered
o MEDICATION OF CHOICE FOR C. DIFFICILE
 Metronidazole (flagyl)
o Education:
 Handwashing
 Avoid
• Fruit juices
• Carbonated beverages
• Gelatins
o All of these things have increased CHO, decreased
electrolyte, and decreased osmolarity
• Caffeine
o Diuretic effect
 BRAT diet is no longer used because it is not nutritious
 o Inform school or child care center (Rotavirus)
o Monitor Labs:
 Specific Gravity
 CBC
 Electrolytes
 Arterial Blood Gases
• For diarrhea you may see Metabolic Acidosis (loss of
Bicarbonate through stool)
o Implement bowel rests
 The first feeding after bowel rest should be cooked cereal

- Diagnoses for Rotavirus and C. Difficile:

o Anxiety
o Diarrhea
o Deficient fluid volume r/t increased peristaltic activity
o Hyperthermia r/t presence of invading organisms
o Imbalanced nutrition: less than body requirements r/t frequent loose
watery stools and vomiting
o Acute pain r/t inflammation
o Impaired skin integrity

- Preparation for admission of a patient with these types of disorders:

o Child will appear:
 LOC:
• Lethargic
• Irritable
 Lung Fields:
• Should be normal if no other problems are arising
 Cardiac:
• Increased pulse (thready)
• Low BP
 Abdomen:
• Distended
• Increased bowel sounds r/t gastrointestinal motility
• Tender upon palpation
• Older child may verbalize cramping, hunched over, and
crying
 Urine:
• Concentration of urine
• Increased urine specific gravity
 Bowel Status:
• Watery stools
• Fowel smelling
 • Color may be GREEN due to the bile
• Frequency increases
• Possibility of blood tinged stool due to inflammation
 Activity level:
• Lethargic
• Clinging to parents
• Not interested in anything else
 Nutrition:
• May not be able to tolerate formula, breast milk, and clear
liquids
o Child may be placed on bowel rest for a few days
with administration of IV fluids.
 Integumentary:
• Turgor:
o Assess on the abdomen for babies
• Diaper area must be cleaned and applied with butt paste
(dry area completely before applying the butt paste)

Types of Pathophysiology Associated with Congenital Gastrointestinal Defects:

- Hirschsprung Disease: gastrointestinal defect that is also called (Mega Colon).

In a normal healthy colon you have nerve cells that trigger muscles to move the
stool down the intestine through the anus and out. In this disease the nerve cells
somehow during development stops developing. Therefore there is no peristaltic
movement and what happens the stool is pushed down and behind it comes more
and causes a major backup. It requires surgery.
o Clinical Manifestations:
 Newborns:
• Failure to pass meconium
• Reluctance to ingest fluids
• Abdominal distention
• Bile stained emesis due to back up
 Infants:
• FTT
• Constipation
• Abdominal distention
• Vomiting and episodic diarrhea because some stool may be
allowed to pass
 Older Children:
• Anorexia
• Chronic constipation
• Foul smelling and ribbon like stools
• Abdominal distention
• Visible peristalsis
 • Palpable fecal mass
• Growth retardation
• Signs of anemia
• Hypoprotenemia (due to disruption in absorption)
o Diagnostics:
 Barium Enema:
• Barium is placed into the intestines and it will detect the
part that is applicable to Hirschsprungs Disease with an X-
ray
 Rectal Biopsy:
• To test for the nerve cell
o Most accurate test
 Anorectal Manometry:
• A small balloon is placed inside of the rectum and normally
the anal muscle will relax once it is placed inside if it does
not then it is diagnosed as Hirschsprung Disease
o Removal Technique:
 Remove a piece with a stoma left, so child may have colostomy
after procedure.
 Pull-through surgery is a type of surgery where they take the
diseased part out, and hopefully they have something to attach it
to.
o Nursing Management:
 Promote adequate hydration
• water
 Promote adequate nutrition
• High fiber foods like bran muffins and cereal
o Secondary infection in small intestines:
 Interocolitis: it can happen before or after surgery for defect
• S/S:
o Fever
o Swollen abdomen
o Vomiting
o Diarrhea
o Bleeding from rectum
o Sluggishness
o Treatment:
 Forceful rectal washouts to decompress the colon
 IV antibiotics
 Colostomy
 Monitor for perintonitis = inflammation of the lining of the
abdomen
 Monitor F/E
 Blood replacement if perfuse amounts of blood are lost
 - Perotinitis:
o Assessment
 Absent bowel sounds
 Severe pain
 High fever
 Increased White blood cells
 Possible shock and death
o Nursing Care of Perotinitis:
 Pain Management
 IV fluid management
 Nasogastric tube to suction
 IV antibiotics

Malabsorption Disorders
Definition: when a child is unable to digest or absorb nutrients in the diet

- Celiac Disease: is more of a diet based disease. A person can not eat gluten,
which is a protein found in meat, rye, and barley. It may also be found in some
medications. It is a hereditary disease, but hard to discover.
o Treatment:
 Gluten free diet
 Work with dietician on what foods to avoid:
• Processed food:
o Cold cuts, hot dogs, salami, french fries, soy sauce,
wheat products, semolina,
o Clinical Manifestations:
 Some times asymptomatic or just a few symptoms
 Gas
 Diarrhea
 Stomach pain
 Feeling very tired
 Anemia
 Weight loss
 Change in mood
 Very itchy rash with blisters
 Slow growth
o Diagnostic:
 Blood test
 Biopsy
Pathophysiolgy of Acquired Gastrointestinal Defects:

- Pyloric Stenosis: thickening and tightening of pyloric sphincter creating an

obstruction. It is common in 1st born males. It is an olive shaped mass. The
 thickening that occurs the hypertrophy areas it presses down on the pyloric
channel causing a stricture. Stenosis occurs between stomach and duodenum
(right upper quadrant). The best time to palpate this olive mass is on an empty
stomach. The abdomen muscles must also be relaxed when palpating so the best
time to do this is when they start to eat (sucking) and the stomach is empty at this
time as well.
o Clinical Manifestations:
 Regurgitation or nonprojectile vomiting starts around 3 weeks of
age
 Then the vomiting will increase in frequency and force over the
next 1-2 weeks and becomes very projectile
 Weight loss, because whatever they eat it comes right back out
 Upper abdominal distention
 Palpable olive shaped mass
 Stools become less frequent with volume decreased
 Signs of malnutrition and dehydration will occur
• Vomiting usually occurs 30-60 minutes after the meal
 You may also observe peristalsis when they are lying down
• Normal peristalsis is from left to right/ theirs will be right
to left making everything come up instead of down
o Diagnostic:
 Ultrasound and Upper GI
 ABG’s : will show metabolic alkalosis:
 Electrolytes:
• Excessive loss of Potassium, Hydrogen, and Chloride
• KNOW VALUES of K, Na, Cl
 CBC:
• Increase BUN indicating dehydration
o Treatment:
 Pylorotomy:
• Procedure is done as soon as infants F/E are stabilized
• The overall goal of the surgery is to release the circular
muscle fibers to allow the passage of food and fluid
• Postoperative Care:
o Position them with the head of bed up 30 degrees to
prevent reflux. But because of the peristaltic action
place them on their right side so that left to right
peristaltic action will develop
o
If the emesis is present during or following the procedure it is considered the infant is
unable to tolerate feedings. So start slow and small.

- Gastroesophageal Reflux: (GERD) gastric contents back up into the esophagus

caused by three mechanisms. It causes gastric distention, and slows gastric
 emptying, hiatal hernias in the presence of gastrostomy tubes. Reflux acidity
damages the esophageal mucosa and can potentially be detrimental to the
respiratory system if aspirated. It can also cause periods of cyanosis. Found more
often in premature babies and infants with other disorders like Cystic Fibrosis and
Cerebral Palsey
o Lower esophageal relaxations
o Incompetent lower esophageal sphincter
o Anatomic disruption of esophagogastric junction

o Clinical Manifestations:
 Forceful vomiting
 Weight loss
 Aspiration
 Cyanotic and apneic episodes that may be life threatening
o Treatment:
 Medicaiton:
• Omeprazole (Prilosec) a PPI which blocks the production
of acid producing cells.
o Diagnostics:
 Upper GI
 Intraesophageal pH monitoring, which is placed down into the
esophagus and measures the pH as the reflux comes up. Nurse
must document pH change
o May require surgery if it wraps around the fundus of the stomach but rare
o This usually goes away as the child gets older and may have a revisit of
the disorder in adulthood

- Potential Signs of GI Emergencies in Infants:

o Esophageal atresia and tracheoesophageal fistula (TEF) is a clinical
and surgical emergency. It is a congenital anomaly in which the
esophagus is not fully developed, so I forms a blind pouch in the upper
esophagus with the large part of the esophagus connected to the trachea.
This is why aspirations occur. It is easily detectable when feeding.
• Cyanosis
• Coughing  characterized by 3 C’s
• Choking
• Also excessive salavation
• Respiratory distress and aspiratory pneumonia
 Nursing Intervention:
• Monitor respiratory status
• Remove excessive secretions (usually continuous suction to
the blind pouch)
 • Put them in an upright reflux position with the head and
shoulders elevated to assist in pulling of the secretions to
the bottom of the pouch
• Provide oxygen as prescribed
• NPO
• Admin IV fluids
 Postoperative Intervention:
• NPO
• Admin IV fluids
• Monitor I/O
• Provide G Tube care and feedings as prescribed
• Because they are new born take care of their Trust vs.
Mistrust as well as Oral Phase (pacifier is needed)
• Monitor for postoperative stricture of the esophagus
o Post surgical complication of TEF
• Promote parent infant bonding

- Appendicitis: is an inflammation of the vermiform appendix, the small sac near

the end of the cecum. Occurs most often in adolescent males 10-19
o Clinical Manifestations:
 Onset:
• Periumbilical cramps
• Abdominal tenderness
• Fever
 Later:
• Pain in right lower abdomen
• Guarding
• Rigidity
• N/V
• Onset of pain before vomiting
• Anorexia
• Rebound tenderness
o Contraindicated because it causes so much pain if
palpated
• Pain induced flexion of the hip (psoas sign)

 Ruptured Appendix:
• Sudden relief of S/S
• Fever
• Abdominal distention
• Rapid shallow breaths
• Pallor
• Chills
  Diagnostic:
• CT scan is most reliable test
 Treatment:
• Immediate surgery
• Child is kept NPO
• IV fluids
• Antibiotics if ruptured
• Nasogastric tube
• Penrose drain is inserted if ruptured before surgery
 Nursing Intervention:
• Position child on side-lying position preoperatively with
knees bent
• Admin analgesics
• Postoperative place the child in semi-Fowlers or side lying
on right side to promote drainage
• DO NOT USE A HEATING PAD
o May induce rupturing and increase inflammation
• Assess fluid volume every 2 hours
• Postoperatively do not administer anything by mouth until
bowel sounds return and start out with small sips of water
and then progress.
• Assess surgical sight for signs of infection

Endocrine Topics
Growth Hormone Injections
Diabetes Insipidus
Syndrome of Inadequate Antidiuretic Hormone
Hyperthyroidism
Diabetes Mellitus
Ketoacidosis

- Growth Hormone Injections:

o Used to treat Hypopituitarism, which is known as growth hormone
deficiency.
o Guidelines for approved indications from the FDA:
 GH deficiency/insufficiency
 Chronic renal insufficiency/pretransplantation
 Turner syndrome
 Short stature from Prader-Willi Syndrome (PWS)
 Children w/ a history of intrauterine growth restriction (small for
gestational age SGA) who have not achieved normal height by two
years of age
 Children with idiopathic short stature who are >2.25 SD below the
mean in height and who are unlikely to catch up in height.
 Adults with growth hormone deficiency
 Adults with AIDS wasting
o Most indications for GH replacement require daily GH injections
 It is being investigated for children with Cystic Fibrosis and other
disorders.
o Effects:
 The child will experience increased growth velocity for the first
year of treatment, followed by a gradual decrease in growth for
subsequent months or years.
 However, growth should progress a least at the normal growth rate
for age while continued on growth hormone treatment.
• If it is slower than improper preparation is the reason
 Therapy is continued until either the child achieves an acceptable
height or growth velocity drops to less than 2cm (1 inch) per year.
 Child should receive close monitoring from an endocrinologist
every 3-4 months.
o Side Effects:
 Arthralgia
 Carpal Tunnel Syndrome
 Myalgia
 Reduced Insulin sensitivity
 Slipped capital femoral epiphysis
 Gynecomastia
 Progression of scoliosis and hypothyroidism
 Benign increased intracranial pressure.
o Additional SE:
 Mild swelling
 Headaches
  Peripheral edema
• Common in children with Turner Syndrome
 Lipoatrophy

- Diabetes Insipidus
o Central Diabetes Insipidus (ADH Deficiency Familial or Idiopathic): there
is a deficient production of ADH
 Clinical Manifestations:
• Polyuria
• Polydipsia
• Nocturia
• Enuresis
• Irritable if fluids with held
• Constipation
• Fever
• Dehydration
 Clinical Therapy:
• Desmopressin acetate (DDAVP)
o Nephrogenic Diabetes Insipidus (Inherited or acquired responsiveness of
kidneys to ADH): kidneys can not respond to ADH. It can be caused from
drug toxicity from drugs such as: (lithium carbonate (Carbolith),
demeclocycline (Delclomycin), amphotericin, cisplatin, foscarnet,
methicillin, and rifampin.
 Clinical Manifestations:
• Polyuria
• Polydipsia
• Hypernatremia in neonatal period
• Dehydration
• Vomiting
• Changes in Mental Status
 Clinical Therapy:
• Diuretics
• High fluid intake
• Salt and protein restricted diet

- SIADH (Syndrome of Inappropriate ADH): hyper secretion of the posterior

pituitary hormone ADH
o Etiology:
 Infection
 Tumors
 CNS disease or trauma
o S/S:
 Related to fluid retention and hypotonicity
 Dilutional hyponatremia
 o Therapy:
 Monitor for fluid overload:
• Restrict fluids
• Accurate I/O
• Daily weight
• Seizure precautions
• Concentrated and decreased urinary output
 Treatment:
• Diuretics
• Demeclocycline (Declomycin)
o Blocks ADH action
• Sodium supplementation

- Diabetes Mellitus

- Diabetic Ketoacidosis:
o Diabetic Ketoacidosis (DKA):
 This occurs in our Type I diabetics
 They present themselves with an elevated glucose
 They are hot and dry (sugar high) very dehydrated
• They need to be re-hydrated with Normal Saline usually a
large infusion rate
 Acidosis always causes CNS depression so they their blood sugar
may not be as high but they become acidotic
 Treat their glucose levels with regular insulin IV infusion along
with a sliding scale
• Now when the blood sugar drops to 250 stop the infusion
and replace fluids with D5W or D5 normal. The reason
being you need to stop ahead of time before because they
have the potential of bottoming out.
 Their K+ is probably high (hyperkalemia) because of
“ACIDOSIS” but watch because they can turn into hypokalemia
because K+ hops on with insulin and glucose enters into the cell.
So treat K+ situation. No need to treat hyperkalemia with Kexalate
because the insulin enough will bring it down.