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5 P’SPAIN- Location- Nature: Stabbing, throbbing, burning?- Frequency: how often? With use of the limb? at rest? Constantly w/no relief?*Remember child may deny pain: they admit to wrongdoing if the admit to pain so they avoid.PALLOR- (skin color)- Warm skin with blue tinge - Possible venous stasis: is cast too tight? - Blood not circulating?- Cool pale skin - Possible arterial insufficiency: cast too tightPARALYSIS (Movement)- Compare bilaterally- Wiggling fingers or toes does not always assess motor damage- Test for nerve damage: ex-ulnar nerve damage They might can wiggle their fingers but they Wont be able to spread them outPARASTHESIA (Sensation)- Hard for a young child to describe- Numb, Tingling - “bugs crawling” - “pins and needles” - “burning” - “asleep”- Loss of sensationPULSE- Assess uninjured limb first to establish Baseline- Don’t forget to assess capillary refill- Assess pulse distal to injury for adequate blood flow ORTHOPEDIC APPLIANCE- Clothing between appliance and skin- No lotion under appliance: makes a moist= yeast growthcont…- No powder under appliance: abrasive; may cause skin breakdown- Toughen skin in contact with metal: to prevent skin breakdown… alcohol or tannic acid- What about balance?* Adolescents have probs wearing braces b/c it prevents them from looking like their peers; especially young girls who are into fashionLEGG-CALVE-PERTHES DISEASEAvascular necrosis of the femoral head (4) stagesPatho1. Blood flow to femoral head is interrupted resulting in bone necrosis2. Blood supply returns femoral head3. New bone4. Remodeling of the new bone: taking the proper shape-if it does not grow to fit the acetabulum correctly they will limp for the rest of their life and have one leg shorter than the other5. Process takes 18 months to several years*not necessarily associated with infection or traumaAssessment- Usually a boy 2-12 yrs old- Slow onset - limp: esp. when they’re tired - pain in thigh, hip, and/or knee - worse with activity, relieved by rest - limited motion - eventually muscle atrophy- definitive test is MRITREATMENT- Keep head of femur in the acetabulum- Treatment plan is influenced by: - child’s age: the younger the better - condition of the femoral head - position with the acetabulum* Keep the femoral head high in the acetabulum so it assumes the proper shapeOVERVIEW TREATMENT- Initial therapy is - Rest - Non-weight bearing - activity can cause microfractures- Conservative versus surgical containment- Later, active motion is encouragedNONSURGICAL CONTAINMENT- Non=weight bearing devices: places femoral head high in the acetabulum - abduction brace - leg casts - leather harness sling- Weight bearing devices - abduction-ambulation braces: most common tx Non-surgical containment cont… - Casts after a period of bed rest and traction- Can take 2-4 yearsSURGICAL INTERVENTION- Osteotomy - screws and plates- Spica Cast - Frequently from chest to toes -6-8 weeks- Physical Therapy - Partial-weight bearing, progress from therePROGNOSIS- Excellent in most cases- Outcome is influenced by - child’s age - early treatment-Possibilities - osteoarthritis - leg length discrepancyOSTEOMYELITISBone infection. Primarily long bone in children- In children: most common b/w 1-12 years- Boys affected more often than girls- Hematogenous spread - organism reaches the bone through blood- Open fracture or wound- S. aureusPatho1. Bacteria adheres to bone2. Purulent exudate in bone tissue3. Exudate moves beneath the periosteum/abscess formation4. Necrosis of the boneASSESSMENT-Fever?- Irritability?- Pain with movement: guarding of affected extremity- Swelling and warmthLAB- Leukocytosis- Elevated ESR: non specific test for inflammation: does not tell us where in body inflammation is located- Cultures - blood and nearest jointLAB cont…- X-Ray, MRI, CT, Bone scanMEDICATION- ABX 4-6 weeks: start with broad spectrum- Important to monitor hematological, renal, hepatic ototoxic, and other potential effects of the ABX- Common medications - nafcillin - clindamycin - VancomycinINTERVENTIONS- Assess and document 5 p’s- Pain - handle with extreme care esp at beginning of tx b/c it will be very tender and painful to move- On bed rest or wheelchair (maybe)- Immobilization (probably): esp at beginning of tx using something like a sling or bi-valve cast.- high protein dietSURGICAL INTERVENTION- Surgical Drain (maybe) - 2 tubes are placed in wound - One tube instills an ABX solution directly to infected Area - one tube provides drainage- Surgical removal of dead bone (sequestrectomy) (maybe)- Not seen as much anymore b/c ABX tx works very well most of the timeSCOLIOSIS- Structural - Adolescent growth spurt - greater than 10 degrees- Functional - result of factors outside spinal column -ex: leg length discrepancy: when they stand the spine curves, but when they sit its st8. -ex: weak muscles that cannot support the Spinal column correctly*Seen most often in girls; can lead to cardiac et respiratory problems b/c not enough space for heart and lungs to function properly*Idiopathic scoliosis is the most common type, and seen most often in the growth spurtsASSESSMENT- Forward Bending Test - Assess standing and bending - Assess symmetry -shoulders, scapulas, waist, hips, -you can look at hems of pants- Scoliometer - Protractor used to measure curvature- Assess for leg length discrepancy*while bending if they have scoliosis, a “rib hump” can be seen… located around the scapula area **classic sign of scoliosisTREATMENT- Serial observation (10-20 degrees): follow up every 3 months and closely monitor growth pattern- Bracing (20-40 degrees) - purpose is to prevent further curvature - usually worn 16-23 hours a day - gradually weaned off brace after spinal growth has stopped: b/c bone demineralization may have occurred from weaning brace for so long so we want to give bone a chance to grow back to normal BRACES- Boston Brace: Standard - TLSO brace (thoracolumbosacral orthotic): custom fit- Milwaukee Brace: for kyphosis* Once bones are ossified (stopped growing) the should not curve anymore; this is why braces are applied before bones have stopped growingSURGICAL INTERVENTION- greater than 40 degree curve: not responsive to bracing - the brace has not corrected the curvature- Realignment and straightening- Instrumentation: rods, screws, platesDEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)- Dysplasia - mildest form - femoral head remains in the acetabulum- Subluxation - Greatest percentage of cases - Incomplete dislocation - head still in contact with acetabulum- Dislocation - Femoral head not in contact with acetabulum INFANT ASSESSMENT- Shortened Limb on affected side- Asymmetry of gluteal folds: makes the legs look pudgy so if it it’s bilateral it is hard to tell- Ortolani click: move legs and you hear a click: that means the joint is in place- Positive Barlow Sign: Passive dislocation**Permanent damage can be caused to hip joint if not done by an experienced clinician or too vigorouslyTREATMENT-Newborn to 6 months- Pavlik Harness - Legs abducted, knees and hips are flexed: holds femoral head high in the acetabulum - Worn continually 3-6 months: straps are only adjusted by the clinician to allow for growth - Very important to catch this early and tx early so that The child will not have a permanent limp and leg Discrepancy for the rest of their lifePAVLIK HARNESS- Position chest halter at nipple line - fasten with Velcro- Position legs and feet in the stirrups - hips are flexed and abducted- Connect the chest halter and leg straps- skin is marked with indelible ink at strap linesTREATMENT- 6-8 months - traction: not seen much anymore - closed reduction under anesthesia: most commonly done first. Traction not used at all - Spica cast: 2-4 months - Brace-Older child - Tenotomy of contracted muscles Muscles have grown and tightened in the wrong direction. These muscles have to be relased - Reconstruction of acetabulum: it is no longer smooth due to overgrowth of tissue there - Cast - Rehab: they may never have a perfect leg or walk FRACTURESBEND- Bent but not broken - May bend 45 degrees or more before breaking because bones are not ossified - Most common in ulna and fibula - often associated with fractures of radius and tibiaTypes of FracturesGREENSTICK - Bent beyond endurance: bone breaks opposite the bend.BUCKLE - Compression of porous bone - occurs near growth plate - tends to be seen in younger children: more towards end of the bone where growth is occurringSPIRAL FRACTURE - Twisting Motion - Planted foot, twist to throw football: someone tackles them and they get a spiral fracture - Skiing - Maltreatment in nonambulating child: someone twists the limb or a limb can get caught on something if a fall occurs.EPIPHYSEAL GROWTH PLATE INJURY - Weakest point of bones - Can result in growth disturbance: permanent damage by stopping growthFRACTURE ASSESSMENTHistory- Child may not be reliable - may be afraid of getting in trouble- Muscle contraction - muscles contract to splint fracture: but they end up pulling the bones farther apart, which leads to swelling- Swelling peaks in 1-2 daysCASTSSwelling & Cast Placement- Swelling peaks 1-2 days - Current trend is to cast 1-2 days after fracture: Initially just wrap in ace bandage or something until swelling reaches it peak - Elevate: after the fracture and after it’s casted above the level of the heart to reduce swelling- Bivalve cast: if needed due to cutting off of circulation to fracture - Cut cast in half and wrap in ace wrap to allow for better circulationTYPES OF CASTSSPICA CASTS- usually have stabilizing bar to help hold the joint in place and are generally in place for 4-6 weeks **do not use the bar to move the child! If the bar breaks, they have to be recasted. Diapers are put into the cast, not over it BIVALVE CAST- Top and bottom of cast held together with elastic bandageSYNTHETIC CASTS - Dry quickly (10-30 minutes) - Lightweight - Can be durable in water: see this more in summer - Manufacturers usually include directions on how to make it durable in water for swimmingCAST APPLICATION- Assess limb for alteration in skin and jewelry - cuts are at risk for infection if casted over- Tube of cloth stockinet over area- Bony prominences covered with cotton sheeting- Wet casting material molded to limb - stockinet may be pulled over rough edges of cast and secured with casting materialCASTS: NURSING- Casts to dry inside out: don’t use anything to artificially dry the outside of the cast- Reposition wet cast with palms and not fingertips to avoid pressure points (hot spots caused by fingerprint indentation that increase pressure on that skin)- After cast has dried, petal cast if needed: Makes sure there are no pointy tips on the cast.ARM SLING- Distributes weight evenly over large area of the shoulders and trunk, not just neck- Discouraged after first few days, especially with short arm cast - encourage normal movement**Worn temporarily; discourage use of sling after a few b/c it restricts movement; movement of the limb potentiates healingA FEW OTHER ITEMS (???)Windows - In a spica cast: Allows abdominal expansion- good for eating so they won’t throw their food back upOdor - Can indicate infection: differentiate between normal ….odor of the cast and the odor of an underlying infectionObject in Cast -Kids may get bored and play with casts… stick toys in itMoisture in cast - urine, shat, vomit… take a wash rag and scoop it out- clean and use a blow dryer5 P’s of circulationCAST REMOVALCast cutter: put on their hand first to show them that it doesn’t cut, it just tickles - buts by vibration - generates heat - noisy- Flakey skin after cast is removed; may take few days to go away with help of showers and lotions; legs may be hairy which is a big deal for girls (in reality its hott)TRACTION-Fatigue muscle to reduce muscle spasms: anesthesia also reduces muscle spasms- Realign bone: need traction and counter-traction to realign correctly- Immobilize during healingCHECK- position of frames, splints, etc- ropes and pulleys - alignment - good working order, not knotted up- Weights - correct amount -hanging freely: not lying on floor- Bed position: pt positioned on backTYPESMANUAL TRACTION - Limb is held in position by person: nurses frequently hold limbs in position while someone else casts itSKIN TRACTION - Pull applied directly to the skin - Primary purpose is to decrease painful muscle spasms - Limited weight to prevent - If “OKed” by physician, remove bandage every 8 hrs to assess skinBUCKS TRACTION - Short term immobilization: buck blue boot, foamy boot; children tend to slide down in bed with this -draw a line on the bed and tell kids their butt shouldn’t slide past that line - Pre-Op Management of: - muscle spasm associated with fractures - Dislocated hip **If traction is released, spasms will come backBRYANT’S TRACTION - *The one where kid lays on back, strapped to bed and legs are pulled vertically - Hip dislocation or fractured femur - weigh less than 40 lbs - buttocks off the bed: this is counter traction - 7-10 days: spica cast maybe - **This type of traction is rarely done - **Increased risk for aspiration - **Blood drains down, out of legsSKELETAL TRACTION - Primary purpose is bone realignment - Pins, wires, tongs, screws are implanted to bone - Longer traction time et heavier wt than skin tractionNURSING ALERTI**f extremity looks pale or is cooler than when you initially assed it, call physician and DO NOT RELEASE TRACTION BY YOURSELF90-90 DEGREE TRACTION- Two 90 degree angles- Steinmann pin or Kirschner Wire in the distal fragment of femur. (large risk for bleeding) - **Not always done under anesthesia b/c sometimes pt is leaking CSF fluid… They may not wake up from anesthesia.- Lower portion of leg is supported in cast boot or sling- Pt. doesn’t have to be mobilizedTRACTION ASSESSMENT- Inspect skina t least every 8 hours- External hardware - Inspect insertion sites for inflammation - drainage - color: of skin and around pin - Odor- Pin Care Controversy - Pin care prevents infection - Pin care disrupts skins natural barrier to infectionTRIAD OF INJURIES- When a kid is hit by a car, assess for: - Broken femur: where bumper meets the bone… depends on the height of child et ht of bumper - Chest injury: hits hood of the car - Head injury: usually land on their headURINARY TRACT INFECTIONINSIDENCE- Pediatrics - 2-6 years old - sexually active girls- Females more often than males - except in neonate period: thought that infants will get UTIs based on an infection elsewhere in the body that spreads-Females - shorter urethra than males - Urethra is in close proximity to anusSINGLE MOST IMPORTANT FACTORURINE STASIS- excellent culture medium- voiding removes bacteria from the bladder and allows more efficient destruction of bacteria remaining on the bladder wall- EXAMPLES - Vesicoureteral reflux - Nerogenic bladder: CNS problem- impulses from brain are not reaching bladder so that bladder does not empty properly (paralysis, spina bifda) - Bladder compression: constipation, pregnancyUA with CULTURE AND SENSITIVITY- Cotton ball in diaper: ok for UA, but not ok for C&S bc it is contaminated with other stuff- Bagged specimens: not of for C&S bc it is easily contaminated- Midstream Clean Catch: - older child: must be able to start and stop urine flow- **Sterile catheter specimen: best for C&S- 100,000 organisms/mL: diagnostic for UTI, but can get dx with less organisms per mL- Gram (-) bacteria- False positive: caused by contaminated organisms from perineal/perianal areas- False negative: caused by children given large volume of fluid… dilutes colony count. **First morning void is most accurateOTHER TESTS- To detect anomalies or Renal Scarring - Renal and bladder ultrasound - Voiding cytoureteral gram (VCUG)SIGNS AND SYMPTOMS-Age of child- Location - Cystitis - Urethra or Bladder - Pyelonephritis - Ureters or kidney NEONATE AND INFANT- Fever- Poor feeding- Vomiting and/or diarrhea- Failure to thrive**Strong smelling urine- Persistent diaper rash*Total body response in infants no matter what the infectionCYSTITS AFTER INFANCY- Frequency and Urgency- Enuresis: bedwetting or incontinence in toilet trained kid- Strong Smelling urine- Dysuria: burning/uncomfortable sensation when voiding - Infants and very young children can’t verbalize discomfort of voiding: ask… do they appear to be uncomfortable when voiding? Are they holding their urine to avoid the pain?PYELONEPHRITIS AFTER INFANCY-High fever and chills- Costovertebral angle tenderness: Put hand right under their ribcage and just gently tap- they will hurt and ask you to stop- Persistent vomiting- moderate to severe diarrhea- dysuria- *frequency and urgencyDESIRED OUTCOMES- eliminate infection- identify contributing factors- Preserve renal function: important for kid under 2 yrs old b/c it can lead to renal damageELIMINATE CURRENT INFECTIONABX; broad spectrum before c&s results are in - eventually based on sensitivity cultures - tech importance of taking ALL the abxEncourage Fluids - flush out pathogens - Carbonated or caffeinated liquids may irritate bladderVoid frequentlyIDENTIFY CONTRIBUTING FACTORS- Is there an anatomical anomaly resulting in urine stasis?- Good Peri hygiene - wiping front to back- Avoid irritants - Bubble baths/shampoos: some babies are bathed in shampoos b/c the parents like the smell, but it can irritate the piss hole and cause infection- Cottong Underwear - allows air through fabric: what really matters is the crotch area… you don’t want it to be wet. Increases risk for infection- Increase fluid intake: esp. if prone to UTIs - Promotes flushing of the normal bladder - Lowers concentration of organisms- Void regularly - Everyone - Sexually active females: void as soon after sex as possible to get rid of bacteria quickly- Acidify Urine - Most pathogens favor an alkaline medium - vegetarian diet increases urine alkalinity - To acidify urine - apple juice, vit. C, Increased protein - Cranberry juice helps prevent bacteria from adhering to bladder wallPRESERVE RENAL FUNCTION- Renal scarring can occur from first infection- Progressive renal injury is greatest in children under 2yr old- Get ultrasounds, more sophisticated testing if 2 and under due to concern about renal scarring and damageVESICOURETERAL REFLUX-reflux of urine up the ureters- very high rate of UTIs with this b/c the pressure in bladder causes some urine to go back up the ureters; after the kid empties, urine comes back down into the bladder and just sits there. It becomes a medium for bacterial growth****Biggest indicator is frequent UTIsTYPES OF REFLUX- Primary Reflux: something wrong with the anatomy - abnormal insertion of ureters into bladder- Secondary reflux: repeated infections cause segment of urethra under mucosa not to compress correctly - Acquired - edema caused by infection - neurogenic bladder- These children have frequent kidney infections (pylenophritis)VOIDING CYSTOURETEROGRAM (VCUG)- Contrast medium is injected into the bladder through a catheter- Catheter removed then picture are taken before, during and after voiding. - kids/teens are asked to piss on a table. Very embarrassing.-Shows urine reflex - grading system 1-5 - 1: up to ureters only - 5: damage to kidneys and twisted up uretersINTERVENTIONS- Daily low dose ABX therapy: taken before bedtime. - abx is metabolized and washes their bladder out overnight - Not associated with candida infections or overgrowth - Examples: Introfurantoin, Bactrim- Liberal Fluids- Regular voiding & double voiding: every 2-3 hours and twice before bedtime** these kids generally grow out of this condition with the help of this abx txURETERAL REIMPLANTATION- High grade reflux- Noncompliance with abx therapy- Infrequent access to health care system: ex-children of migratory workers- Ureter is removed and repositioned in bladder wall in …….more optimal position*Surgical procedure that is done which is associated with noncompliance to abx treatment*post op problems to anticipate is bladder spasms… need meds to preventGLOMERLULAR FILTRATION MEMBRANE- Result is damage to the basement membrane of the glomerulus- Walls of Glomerulus Composed of 3 Layers - Middle layer is glomerular filtration membrane- Filters Blood Resulting in Formation of Urine - Large molecules such as blood and plasma proteins do not pass through the membrane- This is where blood filtration of urine occursNEPHROTIC SYNDROMEIncreased permeability of glmerular filtration membrane***Be able to compare/contrast nephritic syndrome and glomerulonephritisNS: TYPESPRIMARY DISEASE- unknown etilolgy- minimal change nephritic syndrome: most common typeSECONDARY DISEASE- A result of damage to the glomerulus: lupus, CA, heavy metal ingenstionONSET OF NS: minimal change nephritic syndrome in children- Often preceded by a viral illness- Relapsing course throughout childhood: up to 20-30sCLINICAL STATE CHARACTERIZED BY-MASSIVE PROTEINURIA- HYPOALBUMINEMIA- EDEMA- HYPERLIPIDEMIAWHAT HAPPENS IN THE BODY- increased permeability of the glomerular filtration membrane to plasma protein, esp albumin. Albumin crosses membrane and into urine- Massive proteinuria- Hypoalbuminemia: decreased amounts of albuin in blood vesselsTWO REASONS FOR EDEMA- Decrease in plasma osmotic pressure (due to loss of albumin) - fluid moves from intravascular space into interstitial- Hypovolemia - Activates rennin-angiotensinogen mechanism, which leads to conservation of water and increased edemaWHAT ELSE HAPPENS IN THE BODY- As the liver rapidly manufactures replacement proteins, large amounts of lipids are created as well - Hyperlipidemia- At risk for infection - immunoglobulins are lost in addition to albumin loss, esp. IgG… results in altered immunity- At risk for venous thrombosis - Hypovolemia - Loss of Antithrombin III (anticlotting factor)NS: EDEMA- Generalized Edema: head to toe - May develop gradually or rapidly - Eventually brings child into health care system- Pattern - Facial edema especially around the eyes in the morn. - Peripheral - Labila or scrotal swelling - Child will put themselves on bedrest- May gain wt, but lose true body wt. (b/c they’re anorexic and don’t eat well): daily weights done, but can be misleading- Intestinal swelling - ABD pain - Diarrhea- Acites: fluid in the ABD- Pleural effusion - Respiratory difficultyNS: URINE- Decreased Volume - Dark and frothy- Proteinuria - Greater than 3+: probably more than that- May have few RBCs in urineNS: CORTICOSTEROIDS- Initial Treatment - DOC: prednisone 4-6 weeks; especially effective against minimal change nephritis: inexpensive - Positive response in 7-21 days: tapered of until they relapse again - Zero to trace urine protein for a week- Relapse - Increase urine protein - Repeat course of steroid therapyNS: Corticosteroids cont…- Children who do not respond to steroids - other (stronger immunosuppressants) cyclosporineNS: NURSING- Intake and output plus **daily weight- Assessment of edema: assess depth, is it shiny? stretched? Pitting?- “Hide the salt shaker” during acute adematous phase - No foods with high salt conent: pickles, potato chips cured meals - May be fluid restriction during this phase: children don’t do well with it b/c they don’t understand it. They will drink water whenever they can getNS: HOME CARE- Testing urine for albumin- Medication administration- Risk for infection: may not look like it but they are due to prednisone tx and low on IgG- Prognosis - Renal function can be normal or near normal as adult with early detection and prompt treatment in childhoodHEMOLYTIC-UREMIC SYNDROMEhemolytic anemiathrombocytopeniaacute renal failure- Generally seen in children less than 5 years of age- Often linked to a strain of E.coli - raw hamburger meat - unpasteurized milkPATHO1. Toxin damages lining of glomerular arterioles - arterioles become swollen & occluded with platelets fibrin and clots - RBCs are damaged as they passed thru arterioles - Spleen removes damaged RBC -Acute hemolytic anemia2. Platelets Cluster within damaged Vessels - Removal of damaged platelets by spleen - Thrombocytopenia3. Damage to Renal Tubular Cells - Acute Tubular Necrosis - Acute Renal Failure - Chronic Renal failureHUS: ASSESSMENT- Preceded by illness - diarrhea and vomiting - respiratory infection- anorexia, irritability, lethargy- Pallor: anemia- Bruising- Purpura- Rectal bleeding- Oliguria to Anuria- Hematuria- Proteinuria- Possibly CNS involvement: b/c toxins can damage arterioles in CNS… can see seizures/coma- Possibly signs of acute heart failure: - damage to arterioles in heartHUS: NURSING- Hemodialysis- Fluid Replace if needed.. although managed with great care- b/c they are already in fluid overload- Blood transfusion if needed, but done with great caution- Plasma transfusion may be neededHUS: TEACHING- Cook meat thoroughly- Scrub fruits and vegetables- Consume only pasteurized milk- Drink only treated water- wash hands- Outcomes: can recover w/o further damage-** You can die from thisACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITISIncreased permeability of the glomerular filtration membrane caused by damage from immune complexes as a result of GBSPATHO1. Group B hemolytic infection2. immune complexes formed3. immune complexes injure basement membrane4. Basement membrane capillaries occluded by inflamed tissue and leukocytes5. Circulatory congestionAGN: ASSESSMENT- Primarily school age children - peak 6-7 yrs of age - more often in boys- HX of infection: usually strepAGN: EDEMA- Periorbital and Dependent - mild to moderate - may progress in severity - acute edematous phase lasts 4-10 days** Edema in Nephrotic Syndrome more severe than glomerulonephritis AGN: URINALYSIS- RBC, “tea or cola” colored- Casts: hardened material that assume shape of vessel they are in (can have RBC or WBC casts)- 3+ to 4+ proteinuria (not usually high with nephritic syndrome- Elevated specific gravity: both in this and nephritic- Oliguria may or may not be presentAGN: OTHER SIGNS- Sudden elevation of BP- Elevated Antisteptolyisn O titer (ASO titer): - blood test that indicates if a person had strep b4 - elevation in 1 weeks to 1 month - measures antibodies from a recent strep infection- Anorexia, Fatigue, IrritabilityAGN: Complications- Hyper sensitive Encephalopathy - Hyper fusion of the brain with edema - c/o HA: immediately check BP again- Cardiac decomposition - during acute edematous phase- Pulmonary Edema- Renal failureAGN: NURSING- Supportive measure of early identification of complications- Children w/ normal BP and adequate urine output can generally be treated at home… I/Os- Acute Edematous Phase - Usually 4-10 days - Child will generally put themselves on bedrest***There is no treatment for this… it just has to run its courseAGN NURSING CONT….- Elevated BP - Antihypertensive Meds PRN only - Diuretic PRN - Nutrition - Most children regular diet w/ no added salt - bacon, pickles, chips, cured meals - Diet restriction depends upon severity of edema and HTN - Restrict foods with high potassium for children with oliguriaAGN: SIGNS OF IMPROVEMENT-Small increase in urine output with corresponding decrease in body weight - Followed in 1-2 days by copious dieresis: void off fluid like crazy, weight starts going down, bp stops spiking- Reduction in BP with reduction in edemaAGN: DISCHARGE TEACHING-Teach parents - meds: antihypertensives - diet restrictions - s/s of complications- How to: check BP check urine for proteinuria- Follow for at least 1 year: few children go into renal failure, but if child is seen in RF about half of them started with this dz process.ANOMALIES OF THE GENITOURINARY TRACTGENERAL INTERVETIONS R/T SURGICAL REPAIR- Before child has developed body image and castration - b4 preschool period: when they start comparing body parts with other and have fear of castration- Keep dressing clean and dry - change diapers when damp: esp if surgery is in area- Sponge bath- Showers if old enough to know not to soak incisionCRYPTORCHIDISM- Review: normally testes descend - 7-9 months intrauterine life - up to 6 weeks after birth- Cryptorchidism may be bilateral or unilateral - scrotum will appear small and misshapen - Retractile testes is not Cryptorchidism - Balls that move out of the sak after they have already dropped then go back into inguinal canal ex. When you’re cold, they go into body, when warm, they drop back down and hang lowTREATMENT- In majority of infants with crytorchidism, testes decend by 1 yrs old- Chorionic gonadotropin hormone: rarely used due to AE - Gynecomastia - Precocious puberty: very early onset puberty- Orchiopexi - Preferred tx: balls brough down into sack, manually- button sewn onto scrotum to help hold down testes till they grow more and are securely in place - 6-24 months of age - maintain future fertility: sperm don’t like to produe in warm environment like the ABD - Decreases incidence of tumor formation - Above avg risk for testicular cancer with cryptorchidismINGUINAL HERNIA- Protrusion of abd contents through inguinal canal into scrotom- Concern is that it can become incarcerated and cut off circulation into intestines and cause necrosis… leads to death!!- Painless inguinal swelling of variable size - infant: appears during crying or straining - child: appears during crying, straining or standing a long time.INCARCERATED INGUINAL HERNIA- Loop of bowel becomes trapped - intestinal obstruction - gangrene** frequently absorbs by itself and does not require tx; not painful, doesn’t cause infertility HYDROCELE- Fluid in Nuttsack.- Common in newborns - often resolves spontaneously as fluid is gradually absorbed- surgical repair required if hydrocele is not absorbed by 1 yrs old.HYPOSPADIAS- Urinary opening on underside of penis -Epispadias: opening on dorsal surface (top)- Familia: 10-15% have first degree relative w/same cond.**Not circumcised b/c skin needed for the repair is removed with circumcision FREQUENTLY ASSOCIATED WITHChordee - ventral curvature of penis - replacement of normal skin with fibrous band of tissueCryptorchidismHYPOSPADIAS REPAIR- Staged surgical repair - variety of possible procedures based on severity of condition - No circumcision at birth- skin needed for repair.. - preferred age is 6-18 months b4 body image and castration anxiety is developed- Desired outcomes - child able to peee standing and direct it normally - improve appearance of penis: it will never look normal, but it can look “OK” so no one will laugh - produce sexually active organ, if not repaired, no babies PREPARE PARENTS- may expect a perfect penis after surgery- temporary urinary diversion while reconstructed urethra is healing - stent or cath: if stent comes out, surgery is done to put it back**- excessively rstless child may need sedation so they don’t don’t grab tubes- Post-Op epidural pain management may be needed ................
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