-
What are the two classifications for FTT?
- Organic: caused by disease processes
- Nonorganic: lack of parental bonding, psycho-social issues
-
What are the clinical manifestations for FTT?
- Listless
- unresponsive to cuddling
- <5% growth chart for weight and possibly height
- Avoidance of eye contact
- No stranger anxiety
- Delayed development
- Feeding disorders
-
What is rumination, what is a clinical sign, and how is it managed?
- Rumination is voluntary regurgitation
- The infant will improve in a nurturing environment with increased caloric intake
- Long term involvement with home visits to ensure support
- Nonjudgmental attitude is necessary and all systemic/congenital disorders should be ruled out
-
How would you assess for FTT?
- Complete history of problem and diet
- Feeding, stooling, and sleeping pattern
- Psychosocial history
- Parent-child interactions
- H to T physical assessment and growth chart
- Developmental assessments and milestones
- SAFETY (is it safe for this child to be at home???)
-
How is FTT treated?
- Nutritional Supplementation (vits, minerals, caloric boosters, protein increased)
- Offer support-home visits
- Psycho-social therapy/parenting class
- Daily/weekly weights
-
What are kwashiokor and Marasmus?
- Kwashiokor: protein deficiency
- Marasmus: Protein and caloric deficiency
-
What are Rickets, scurvy, beriberi, and pellagra?
- Rickets: Vit D (all infants should have 200 mg vit D daily), Calcium & Phosphorus deficiency
- Scurvy: Vit C Deficiency
- Beriberi: B1-Thyamine deficiency
- Pellagra: B3 Vitamin and Anacin deficiency
-
When thinking about caloric intake, what are some important things to consider?
- Formula normally has 20kcal/oz, so higher caloric formula may be needed
- Improve fluid intake and monitor i/o
- Prevent infection, promote skin integrity, and sensory stimulation
-
Discuss the importance of fluids to an infant
- A premature infant is 90% water, while a term infant is 75-80% water, a child is 65% water
- Infants have a higher amount of extracellular fluid and 1/2 of it is exchanged every day
- Glomerular filtration reaches adult rate by 2 y/o (infants have dilute urine)
- Increased resp rate leads to increased insensible fluid loss
- Greater fluid loss thru skin due to greater body surface per kg
-
What is the average urine output for an infant and school age child?
- Infant: 5-10 ml/hr
- 1-10 yrs: 10-25 ml/hr
- 11+: 35 ml/hr
-
What are causes of diarrhea and Gastroenteritis in the infant? What is the main risk?
- Can be caused by dehydration, lactose intolerance, or infection (gastroenteritis)
- Infectious agents include Salmonella, Shigella, E. Coli, rotavirus, giardia, and c. diff
- *Main complication is dehydration
-
What is the primary type of dehydration in children?
- Isotonic is the primary form of dehydration in children
- This is a balanced loss of both water and electrolytes
- The major loss is in ECF, leading to decreased circulating blood
- Major complication is hypovolemic shock
- Sodium labs will be normal at 130-150 meq/L
-
What is hypotonic dehydration?
- Losing more electrolyte than water, leading fluid to enter the cells
- May occur if electrolytes are not replaced during fluid loss (giving only water)
- Also decreases circulating blood (fluid goes into ICF) and risk of hypovolemic shock
- Sodium labs will be BELOW 130-150 meq/L
-
What is hypertonic dehydration?
- Losing more water than electrolytes, due to either loss of water or increase in electrolyte replacement
- Fluid shifts from ICF to ECF
- Neurological changes
- Sodium labs HIGHER than 130-150 meq/L
- *When introducing replacement fluids, monitor for cerebral edema and water toxicity
-
Describe mild dehydration
- 3-5% wt loss in infants
- Vitals normal and tears present with thirst
- Decreased UO
- May be pale in color
- Mucus Membranes and fontanels normal
- Cap refill >2sec
- Increased urine specific grav
- Normal behavior
-
Describe moderate dehydration in the infant
- 609% wt loss
- Slight tachycardia and hypertension
- Cap refill 2-4 sec with decreased skin turgor
- Gray in color
- Dry mucous membranes with decreased tearing
- Mod thirst
- Oliguria with increase in urine specific gravity
- Anterior fontanel may be sunken
- Irritable in nature
-
Describe severe dehydration in the infant
- >10% wt loss
- Cool, mottled skin with tenting
- Cap refill >4sec
- Pulse is rapid and thready with orthostatic BP
- Absent tears with sunken eyes and fontanels
- Mucus membranes are dry and cracked
- Oliguria or anuria
- Hyperirritable or lethargic in nature
-
What complications can arise from dehydration?
- Hypokalemia, hypocalcemia, and hyponatremia
- Hypovolemic shock
-
What are the early signs of hypovolemic shock in the infant?
- Mild tachycardia with Normal BP
- Thirst
- Pallor
- Irritability and apprehension
- Decreased UO
- Min UO 1-2ml/kg/hr
- Decreased cap refill in hands and feet
-
What are the clinical manifestations of hypovolemic shock in infants?
- Hypotension
- Tissue Hypoxia
- Apnea
- Increased resp rate to compensate for metabolic acidosis
- Skin is cold and clammy
- Decreased central venous pressure
- Altered LOC
- Decreased glomerular filtration rate
- If UO decreases below 1-2ml/kg/hr, renal failure will occur
-
What interventions can be done for rehydration of an infant?
- Mild dehydration: Oral Rehydration Solution 40-50 ml/kg over 4 hrs
- Mod Dehydration: ORS 100 ml/kg over 4 hrs
- Severe Dehydration: IV LR 40 ml/kg/hr until pulse and LOC return to normal
- *ORS is 75-90 meq Na/L
-
How do you replace stool loss for rehydration in the infant?
- Replace 1:1 if stool losses are known
- Infants: 10ml/kg for each diarrhea stool
- Child: 100-150 ml for each diarrhea stool
- *Daily volume maintenance hydration should not exceed 150ml/kg/day
-
How do you calculate maintenance fluids for the infant?
- 100 ml/kg/day up to 10 kg
- Add 50ml for each additional kg up to 20 kg
- If greater than 20 kg, 1500ml and then add 20ml for every additional kg over 20
-
How is dehydration diagnosed?
- Elevated HCT
- Decreased Potassium & Sodium
- Elevated BUN due to decrease in renal circ
- CBC may be increased with infection
- Stool sample show low pH with increased sugar
- Stool sample may show leukocytes if caused by an enteroinvasive organism
-
What nursing interventions and medications can be given for dehydration? What interventions should not be used?
- Strict I/O and daily weights
- maintenance and replacement fluids
- Reintroduce fluids slowly if NPO for bowel rest
- Pedialyte for children under 2 yrs
- If infant tolerates pedialyte, may mix with formula to make 1/2 strength
- If child is over 2, ORS, weak tea, flat soda, or reg diet may be used
-
How can diarrhea be prevented in the infant?
- teach personal hygiene as most diarrhea is by agents spread by fecal oral route
- Clean water supply protected from contamination
- Careful food prep
- hand washing!!!!
-
What is colic? What is it commonly related to? What medications and interventions can be used?
- Colic: paroxysms of irritability, fussing, or crying that starts and stops with no obvious cause (3hr + for 3 days/wk)
- Colic is self limiting
- Common with allergies such as dairy (in mom's milk) so rule out all allergies
- Medications include simethicone drops PO to relieve intestinal gas
- Change infant's position frequently
-
What is gastroesophageal reflux?
- This occurs in everyone but frequency and persistence make it abnormal
- GERD has tissue damage
- 50% of infants 2mo ave GER that usually resolves within 12 mo
- usually occurs from relaxation of the lower esophageal sphincter
- Inflammation from acids causes symptoms
-
What is GER diagnosed? How is it different from GERD?
- GER is diagnosed y hst and PE
- Upper Gi series can detect pyloric stenosis, malrotation, hiatial hernia, or strictures
- 24hr Intra-esophageal ph monitoring study may be done
- GER does not occur with tissue damage, unlike GERD
-
How is GER treated?
- Ger is symptomatically treated by mixing 1tsp-1tbs of rice cereal per oz of formula
- Upright position maintained after feedings
- Prone position may be indicated if severity of GER outweighs risk of SIDS
- tagamet, zantac, pepcid, prevacid, and prilosec may be given
- Nissen fundoplication: surgical procedure that wraps the gastric fundus around the esophagus to prevent reflux
-
Define anemia. What are the common types of anemia found in children?
- Anemia is common in childhood and may result from inadequate RBC production or hemoglobin or excessive loss or both
- Iron Deficiency Anemia
- Hemorrhagic Anemia
- Hemolytic Anemia (congenital or acquired)
- *chronic anemias can cause CHF, growth restriction and decreased sexual maturation
-
Why is iron deficient anemia common in infants? How is it diagnosed? How can be prevented and how is it treated?
- Fetal iron stores only last 5-6mo
- Most common from 12-36mo
- After 1yr, infants that drink dairy milk interferes with oral iron absorption
- Diagnosed by a Hemoglobin <11g/dl and Hct <33%
- treated by increased oral intake with iron fortified ceral and formula (give with vit c)
- Also treated with oral ferrous sulfate (can stain teeth!)
- Severe anemia requires Imferon IV or IM or blood transfusions
-
Which children are at risk for Sickle Cell anemia?
- It is a heredity disease common to people of African American descent along with Hispanics
- When both parents are carriers of the sickle cell trait, the child has a 25% chance of developing sickle cell anemia
-
Why is sickle cell generally not seen at birth and therefore requires newborn screening?
- Fetal hemoglobin (HgbF) decreases during the first year of life
- HgbF does not sickle and therefore masks the disease
- newborn screening can be done to detect SCA
-
Describe the pathophysiology of sickle cell anemia
- Hypoxia causes RBCs to scikle causing obstruction, RBC destruction, and further hypoxia
- Vaso-occlusion results in pain, tissue ischemia, and infarction
- This can lead to tissue or organ enlargement,tissue death, and scarring
-
What are the s/s of a sickle cell crisis?
- Vaso-occlusive crisis are incredibly painful
- Sequestian Crisis is a pooling of red blood cells in the liver and spleen leading to splenomegaly and hepatomegaly
- Aplastic crisis- diminished RBC production
- Hyper hemolytic crisis is an accelerated destruction of RBCs
- CVA can occur due to blockages in the major blood vessels in the brain
- Acute chest syndrome is similar to pneumonia
- Infection is one of the main causes of a sickle cell crisis and s/s of infection may also be present!!
-
How is sickle cell anemia diagnosed?
- newborn screening
- Sickledex from finger stick will be positive for SCA will not show carrier or SCD. Positive Sickledex is an indication for electrophoresis
- HgB electrophoresis to determine if carrier or SCD
-
How is SCD treated and what is the prognosis?
- Hydroxyurea may be used to maintain hemodilution
- Opioids RTC and PRN on PCA pump for pain (such as morphine)
- Adequate hydration and rest with possible O2 use
- Electrolyte replacement with transfusions to treat anemia (may need kelation therapy for iron build up)
- Antibiotics to treat any existing infection (prophylactic penicillin)
- *child without w/w can participate in reg activities, but may have physical and sexual delays. Infection is the major complication in children under 5 y/o
-
What are nursing interventions for SCD?
- Educate the family and the child to seek early intervention with a fever of 101 F or if infection is suspected
- Give prophylactic antibiotics (such as penicillin)
- Recognize s/s of splenic sequestration requiring splenectomy
- Treat the child normally
- Stress the importance of adequate hydration!!
- Depression, anxiety, and other psych disturbances are common due to pain and other restrictions
-
Describe acute nasopharyngitis, the s/s, and its treatment
- Acute Nasopharyngitis is the common cold often caused by rhinovirus, RSv, adenovirus, or influenza virus
- In children over 3 mo they may have a high fever, but younger children may be afebrile
- May be accompanied with /v/d due to accumulated mucus drainage in the GI
- Treatment includes rest, increasing fluids, NS nose drops, bulb suction and measures for fever reduction (no ASA!)
- Decongestant nose drops may be given to infants older than 6mo for 3 days or less
- May progress to OM due to nasal congestion
-
Why is ASA avoided in children with viruses?
Associated with Reyes Syndrome
-
Describe acute otitis media, its s/s, dx, and treatment
- One of the most common infectious disease in infants due to the short, wide, and straight nature of the Eustachian tubes
- Can be caused RSV,influenza, Hib
- s/s include bulging red or yellow eardrum, purulent drainage if ruptured with pain
- Infant will have acute acute pain with irritability and tugging on ears
- Amoxicillin may be given for 10-14 days
- Myringotomy may be performed to relieve middle ear pressure
-
What is OME and how is it dx and treated?
- Fever and bulging tampanic membrane with little or no pain
- Tm will be immobile with an orange discoloration
- Anitbiotics only if the effusion >3 mo
- Tympanostomy (tubes) to equalize pressure and drain fluid from middle ear
-
What should parents be taught if their child has OME?
- Complete the full course of antibiotics
- Tylenol or warm/cold packs
- temporary hearing loss during infection and for up to months after
- Use ear plugs when exposed to water if tympanostomy tubes are present
- Prevent OM by not propping bottles,smoke free environment, and avoiding allergens
-
What is acute bronchiolitis?
- Frequently seen in the first 6 mo of life and rarely after 2 yrs of age
- RSV responsible for 80%
- Most common on winter/early spring
- Bronchioles swollen with mucus and exudate
- Obstruction leads to hyperinflation, obstructive emphysema, and patchy atelectesis
-
What are the s/s of acute bronchiolitis?
- Begins as an URI
- OM and conjunctivitis may be present
- Tight cough, retractions, cyanosis, barrel chest, may become dehydration
- X-rays show hyperinflation
- Apnea may eb present
- Increased PaCO2 leads to resp acidosis
- Hypoxemia (Decrease O2 sat)
-
How is acute bronchiolitis dx and treated?
- NSS instilled into nostril and aspired for RSV testing
- Treated with fluids,rest, humidified O2
- Periodic suctioning
- Bronchodilators
- Contact isolation and hand washing!!!
- Ribavarin (Virazole) aerosol to treat virus (very controversial and only used for high risk)
-
How can RSV be prevented?
- Palivizumab- monoclonal antibody in monthly IM injections preferred for most high risk children, infants with bpd, and those with congential heart disease
- RSV Prophylaxis is recommended for all infants born <32 wks gestation and is given from Nov - Mar when RSV is most common
-
What type of bacterial pneumonia is most common in infant and children? When is it most likely to occur?
- Pneumococcal Pneumonia is the most common in infants and children (incidence decreased by vaccination)
- Usually bronchial rather than lobular
- Often occurs secondary to URI
-
What are the clinical manifestations of bacterial pneumonia and how is it treated?
- Abrupt, high fever
- marked resp distress with flaring, retractions, circumoral cyanosis
- tachycardia, tachypnea
- Cough, chest pain, meningeal symptoms
- Pain can be referred to abdomen
- Abd distension due to swallowed air or paralytic ileus
- Treated by antibiotics
- O2 and IV fluids
- Cluster Care for rest
- Antipyretics and suctioning
- Elevate HOB
- Support Family
-
What is Sudden Infant Death Syndrome? What are some suspected causes?
- "The death of an infant under 1 yr of age which remains unexplained after a complete postmortem examination, including an investigation of the death scene and review of case history"
- Cause is unknown, but may be brainstem abnormalities, overheating, suffocation, and smoking in the home
-
What are the characteristics commonly associated with SIDS?
- Frequently age between 2-3 mo
- Low birth weight
- Winter
- Male
- Lower socioeconomic
- Mother under 20 y/o
- Mother smokes
- Not the first born
- Sleeping in the prone position
-
What are some common findings in infants who have died from SIDS?
- Infant often found in a disheveled bed with blankets over head an huddled in corner
- Mouth may be frothy, blood tinged fluid
- Infant lying face down
- Diaper full of urine and stool
- Hands may be clutching sheet
- Autopsy may reveal mild resp distress
-
What are some considerations nurses should take when interacting with a family who has suffered a loss from SIDS?
- Family is in shock and guilt can be overwhelming
- Grieving is a process and family may project feelings
- Only ask factual questions
- Allow parents to say goodbye to the infant
- Follow up with home visits; SIDs printed info
- Support group referral
-
What are Apparent Life Threatening Events (ALTE)?
- Apnea of infancy >20sec
- Color Change- pallor or cyanosis
- Hypotonia
- Chocking or gagging
- Slight increased risk for SIDs
- Relate to other disorders
- Continue home monitoring and make sure parents know CPR
-
Describe Hydrocele, cryptorchidism, and orchiopexy
- Hydrocele: collection of peritoneal fluid that accumulates in the scrotum (surgery if persists past 1 yr)
- Cryptorchidism: undescended testicles (if not corrected, sterility can result)
- Orchiopexy: surgical procedure to bring testes down, usually done between 1-2 years of age
-
Describe a UTI in the infant, the tx, and tips for prevention
- Fairly common in diaper age, more so in females due to anatomy. E coli most common cause
- Fever, n/v, irritability, darkened urine, frequency
- Clean catch urine specimen to culture
- Treated with antibiotics at home
- Prevent by keeping perineal area clean, changing diapers on time, washing hands, and poss cranberry supplements
-
What is Wilm's tumor? What should you never do if Wilm's tumor is suspected?
- An Adenosarcoma in the kidney region and is one of the most common of the abdominal neoplasms in early childhood
- Never palpate as it may burst!
- Treatment includes removal of kidney, chemo & radiation
-
What are febrile seizures and how are they treated?
- Seizures associated with a febrile illness in the absence of CNS infection or electrolyte imbalance
- Most common between 6-36 mo when temp >101.8
- Seizure precautions are most important during an event
- IV or rectal valium is the drug of choice
- Tylenol may bring fever down but does not prevent or stop seizures
- If seizure lasts >5min, the parents should call 911
-
What nursing interventions should be performed for a child with seizures?
- Make sure infant is in a safe place
- Turn onto side to prevent aspiration
- Have 02 and suction equipment ready
- Ambu bag should be kept at bedside
- Pad the crib rails
- Document the type of movements, the duration, pulse & resp, color, eye deviation, and postictal state
-
What are some common head traumas in infants? What are some complications from head trauma?
- Common head traumas in infants include skull fractures, contusions, and hematomas
- Complications include increased ICP, cerebral edema, infection, brain damage, hemorrhage and death
-
When should a parent seek treatment after head trauma?
- Significant fall or loss of consciousness
- Amnesia or severe HA
- Fluids leaking from ears or nose (+ for glucose means CSF fluid)
- Vomiting 3x+
- Confusion, unsteady gait, change in vision
- Neck pain
- Bruising below eyes (basilar fracture)
- Pupils dilated, unequal, or fixed (neuro emergency!!)
-
What assessments are essential for head trauma?
- CAB
- Stabilize spine
- Clean any abrasions
- NPO then advance to clears if normal LOC
- Assess for pain (cannot give meds)
- Assess neuro q4hr
-
What are some common skin and mucous membrane disorders of the infant? How are they treated?
- Miliaria Rubra: prickly heat rash. No tx
- Diaper Rash: tx with zinc cream
- Candidiasis: Yeast infec treated with anti-fungal such as nystatin
- Seborrheic Dermatitis: also called cradle cap. Due to excessive sebaceous glands. Leave oil on head overnight to loosen crusts
- Impetigo: characterized by yellow crusts. Crusts removed by Barlows solution and treated with antibiotics
- Acute Infantile Eczema: also called atopic dermatitis. Treated with creams and lotions
|
|
