NR 328 Exam 2 Study Guide

NR 328 Exam 2 Study Guide NR 328 Exam 2 Study Guide Fluid & Electrolytes Chapter 29: • Signs and symptoms of fluid overload pg. 1056 pg. 949 & 956-957 Generalized edema, pulmonary edema (moist rales & crackles), Hepatomegaly, slow bounding pulse, weight gain, lethargy, elevated venous pressure, seizures, coma. Lab findings: Decreased serum electrolytes, low urine specific gravity, decreased hematocrit, variable urine volume. • Signs and symptoms of fluid deficit pg. 1056 pg. 949 & 951-955 Top 3: #1 Poor skin turgor #2 abnormal respirations= Tachypnea #3 Prolonged capillary refill 2 secs Tachycardia, dry skin & mucous membranes, sunken eyes & fontanels, irritability, lethargy, thirst, weight loss, diminished urine output, and altered level of consciousness, disorientation. Lab findings: High urine specific gravity, increased hematocrit, increased BUN, increased serum osmolality • Hypo and hyperkalemia & Foods that contain potassium Pg. 1359 pg. 1271  Hypokalemia: o 3.5 mEq/L o Abnormal EKG; notched or flattened T waves, decreased ST segment, premature ventricular contractions o Muscle weakness, cramping, stiffness, paralysis, hyporeflexia, hypotension, cardiac arrhythmias, gallop rhythm, tachycardia or bradycardia, ileus, apathy, drowsiness, irritability, fatigue  Hyperkalemia: o 5.5 mEq/L o Variable urine volume o Flat P wave on ECG, peaked T waves, widened QRS complex, increased PR interval o Muscle weakness, flaccid paralysis, twitching, hyperreflexia, bradycardia, ventricular fibrillation and cardiac arrest, oliguria, apnea—respiratory arrest  Foods that contain potassium: Foods with thick skin: Oranges, banana, nuts, squash, carrots, broccoli, kale, tomatoes, beans, avocado, fish, mushrooms • Signs and symptoms of hypo & hypernatremia pg. 1056 pg. 949-950  Hyponatremia (less than 135 mEq): anorexia, nausea, vomiting, weakness, lethargy, confusion, muscle cramps, twitching, & seizures.  Hypernatremia (more than 145 mEq): Thirst, hyperpyrexia (Extremely high fever), sticky mucous membranes, dry mouth, oliguria (diminished urine output) hallucinations, lethargy, irritability, & seizures. • Types of dehydration: Isotonic, hypotonic, hypertonic (see Ecollege:DocSharing: Powerpoints: GI dysfunction)  Babies= ECF ICF (75% water) leads to more rapid loss  Isotonic Dehydration: This is the primary form of dehydration occurring in children (Na remains normal since H2O loss and electrolyte loss are equal. Leads to shock) H2O loss = electrolyte loss  hypovolemic shock. The major loss is from the ECF. Symptoms are related to hypovolemic shock  Hypotonic Dehydration: Dehydration occurs when the electrolyte deficit exceeds the water deficit. Water moves from ECF to ICF which further increases the ECF volume loss and leads to shock. (Na level usually less than 130 mEq/L) Electrolyte loss H2O loss  shock & seizures (low sodium)  Hypertonic Dehydration: Dehydration results from water loss in excess of electrolyte loss and is usually caused by a proportionately larger loss of water or a larger intake of electrolytes. This type of dehydration is the most dangerous and requires much more specific fluid of therapy. (Na level usually greater than 150 mEq/L Causes lethargy, seizures, hyperirritability to stimuli losing fluid from the ICF) H20 loss electrolyte loss  neuro. • Nursing care of dehydration: oral & intravenous rehydration, reintroduction of regular diet The major goals in the management of acute dehydration include 1) assessment of fluid and electrolyte imbalance, 2) rehydration 3) maintenance fluid therapy, and 4) reintroduction of an adequate diet. Treat infants and children with acute diarrhea and dehydration first with oral rehydration therapy (ORT). ORT is one of the major worldwide health care advances. It is more effective, safer, less painful, and less costly than IV rehydration. Oral rehydration solutions (ORSs) enhance and promote the reabsorption of sodium and water. These solutions greatly reduce vomiting, volume loss from diarrhea, and the duration of the illness. Rehydration with oral solutions can be used over 4-6hours of mild to moderate dehydration. IV rehydration (Normal saline 20ml/kg; lactated ringers 20ml/kg  infuse over 20minutes. You need a doctor’s order to do a bolus) if severe and unable to take by mouth (PO). Reintroduction of regular diet after rehydration. • Know the formula for calculating the daily fluid requirements based on kg weight of a child pg.947  1-10kg = 100ml/kg  11-20kg = 1000ml + 50ml/kg for each kg 10kg  20kg = 1500ml + 20ml/kg for each kg 20 kg Cardiovascular concepts Chapter 34: • Review VSD, coarctation of the aorta symptoms, expected labs, nursing diagnoses  Ventricular Septal Defect (VSD): is an abnormal opening between the right and left ventricles. 20-60% of VSDs close spontaneously (spontaneous closing is more likely to happen during the first year of life in children having small or moderate defects).  Signs and symptoms of VSD: murmur, poor feeding and failure to thrive, fast breathing and fatigue & SOB. It is classified under increased pulmonary blood flow (acyanotic defect).  Diagnostic tests (9th edition table 34-1 procedures for cardiac diagnosis pg 1346 is a good table): Radiologic imaging (chest X-ray), Electrocardiography, Echocardiography, Cardiac catheterization (most invasive), Cardiac magnetic resonance imaging.  Coarctation of the aorta symptoms (obstructive defect): is a narrowing of the aorta. When this occurs, your heart must pump harder to force blood through the narrow part of your aorta. Symptoms include: Pale skin, irritability, heavy sweating, difficulty breathing, murmur, a weak or delayed pulse, high blood pressure, and difficulty feeding (failure to thrive).  Nursing diagnoses: o Fluid volume excess related to edema secondary to CHF o Impaired gas exchange related pulmonary congestion secondary to increased pulmonary blood flow o Imbalanced nutrition: Less than body requirements related to respiratory distress, feeding difficulties o Interrupted Family Processes related to presence of a child with a life threatening illness o Activity intolerance related to respiratory distress, fatigue o Decreased Cardiac Output related to structural defect, myocardial dysfunction, altered hemodynamics o Ineffective breathing pattern related to pulmonary congestion, decreased cardiac output • Care of the child with a cardiac defect & prevention of stroke  Feeding interventions: o Small frequent feedings with 24 cal formula (more calories, less work) o Neutral environmental temperature o Limit feeds to 30 minutes  Position upright to feed, and position on R side after feeding, HOB ↑ 30-45 degrees  Monitor for feeding tolerance  Consider gavage feedings  Make sure the patient is well rested to conserve energy  Provide oxygen and make sure they are getting enough perfusion • Tet spells in TOF (tetralogy of Fallot) and nursing care of tet spells  TOF (cyanotic or decreased pulmonary flow): 4 defects make up this congenital heart defects. 1) A hole in the walls between the two sides of the heart 2) Narrowing (stenosis) of the main artery 3) Abnormal thickening of the right ventricle 4) Abnormality in the position of the main artery.  Nursing Care: 1) Place infant in knee-chest position 2) Employ a calm, comforting approach 3) Administer 100% oxygen by face mask 4) Give morphine subcutaneously or through existing intravenous line 5) Begin intravenous fluid replacement and volume expansion, if needed 6) May give propranolol 7) Repeat morphine administration.  Blalock Taussig Shunt (may be done as well) o Teaching after surgery includes:  1) Good hand hygiene  2) Conserve energy  3) May need tube feedings  4) Avoid infectious people  5) Digoxin, diuretics, possibly ASA to prevent platelet aggregation  6) Report increased cyanosis post-op, which indicates shunt occlusion  7) Avoid dehydration!! • Cardiac catheterization and care and assessment before & after procedure  Cardiac Catheterization: a radiopaque catheter is inserted through a peripheral blood vessel into the heart. The catheter is usually introduced through a percutaneous puncture into the femoral vein.  Nursing Care: possible complications include acute hemorrhage from the entry site, low grade fever, nausea, vomiting, and loss of pulse in the catheterized extremity (usually resulting from a clot, hematoma, or intimal tear), & transient dysrhythmias. Therefore it is essential that the nurse employ good nursing judgment and physical assessment before and after procedure.  Pre-procedural care: complete nursing assessment including height & weight. Obtain a history of allergic reactions since some of the contrast agents are iodine based. Severe diaper rash is a reason to cancel the procedure if femoral access is required (notify physician). Assess pedal/ femoral pulses and mark their locations before the child goes for procedure. Record baseline O2 sat in children with cyanosis. Keep the child NPO before procedure although polycythemic infants and children may require IV fluids to prevent dehydration, and neonates may need dextrose solution for up to 2 hours before the procedure to prevent hypoglycemia. Oral drugs are withheld the morning of the procedure but may be verified with physician beforehand.  Post-procedural care: May recover from the procedure in a recovery unit or in hospital room. Some may require ICU care. Patients are usually placed on a cardiac monitor and a pulse oximeter for the first few hours after catheterization. Most important things to look for: Pulses, especially below the catheterization site, for equality and symmetry (it may be weaker for the first few hours but should gradually increase in strength); Temperature and color of the affected extremity since coolness or blanching may indicate arterial obstruction; Vital signs which may be taken as frequently as every 15 minutes with special emphasis on the heart rate, which is counted for 1 full minute for evidence of dysrhythmias or bradycardia.; BP for hypotension which may indicate hemorrhage from cardiac perforation or bleeding at the site of initial catheterization; Dressing, for evidence of bleeding or hematoma formation in the femoral or antecubital area(log roll patient to check the back of the patient for bleeding as well). Put pressure (sandbag) if bleeding and notify physician; Fluid intake, both IV and oral, to ensure adequate hydration. Keep child laying flat during and after procedure  Infants are at high risk for hypoglycemia and should receive dextrose containing IV fluids and blood glucose levels should be checked. • Use of diuretics, digoxin, precautions, teaching, signs and symptoms of toxicity  Diuretics (Table 29-2): Used to remove accumulated fluid and sodium. Because furosemide (lasix) & thiazides cause loss of potassium, the child should be given potassium supplements and rich dietary sources of the electrolyte. A fall in the serum potassium level enhances the effects of digoxin, increasing the risk of digoxin toxicity. (Watch signs of hypo/hyperkalemia) Record fluid intake & output & also monitor daily weight at the same time each day to evaluate the benefit of the drug. Give diuretics early in the day to children who are toilet trained to avoid the need to urinate at night.  Digoxin (3 major actions): 1) it increases the force of contraction (positive inotropic), 2) it decreases heart rate (negative Chronotropic) & slows the conduction of impulses through the AV node & 3) it indirectly enhances dieresis by increasing renal perfusion. Give digoxin at regular intervals usually every 12hrs such as 8am & 8pm. DO not mix with foods or drinks. Therapeutic serum dig levels range from 0.8 to 2 mcg/L. Observe for signs and symptoms of toxicity such as bradycardia, vomiting, anorexia, and nausea. If child vomits, do not give a second dose. If dig toxicity, use the antidote Digoxin Immune Fab. • Cholesterol screening recommendations pg. 1396 EBP pg. 1308 (diagnostic evaluation) • Selective screening of children over the age of 2 years who have a sibling, parent, or grandparent with an elevated cholesterol level of 240mg/dl or higher. Children should be screened if they have a first or second- degree relative with early atherosclerotic disease (Stroke, MI, Sudden cardiac death, angina, PVD). Screening should be done if the child has any individual risk factors such as diabetes, hypertension, and obesity, a history of Kawasaki disease or nephrotic syndrome. Screening should include a fasting lipid profile in these patients. Cholesterol screening should be performed if the child’s genetic family history is unknown. • Kawasaki’s disease: signs and symptoms, nursing care for comfort • Kawasaki disease is an acute systemic vasculitis of unknown cause (inflammation of the small and medium sized blood vessels with the coronary arteries being the most susceptible to damage). The illness is self-limiting & resolves in 6 to 8 weeks. Without treatment, approximately 20% to 25% of children develop cardiac sequelae (a condition resulting from a prior disease). • Signs & symptoms (3 phases): Acute phase: abrupt onset of high fever (it is unresponsive to antipyretics & antibiotics), conjunctivae becomes red, eyes are dry, inflammation of the pharynx and oral mucosa with red cracked lips and the characteristic “strawberry tongue”. Rash in perineum, hands are feet are edematous, palms and soles become erythematous. • Subacute Phase: Resolution of fever and lasts until all outward clinical signs has disappeared. Periungual desquamation (peeling that begins under the fingertips & toes) of the hands and feet. Thrombocytosis & hypercoagulability in a child with expanding aneurysms and disrupted blood flow place him or her at risk for coronary thrombosis. Arthritis and irritability may persist. • Convalescent Phase: clinical signs have mostly resolved but lab values are still abnormal. The erythrocyte sedimentation rate and C-reactive protein level may remain elevated, which reflects lingering inflammation. Thrombocytosis may still be present. Arthritis may continue into this stage. This phase ends when all blood values return to normal (6 to 8weeks after onset) • Nursing care for comfort: focuses on symptomatic relief, emotional support, diagnostic assistance, medication administration, and education of the child and family. Monitor cardiac status. Record Intake, output and daily weights. Minimize skin discomfort with application of cool cloths and unscented lotions and use of soft, loose clothing. Provide mouth care & apply lubricating lip ointment to help mucosal inflammation. Offer clear liquids and soft foods & monitor temperature carefully. It is important to document temperature just before aspirin administration (if the fever is very high, acetaminophen may be given in addition to high dose aspirin). Passive range of motion should be indicated for arthritis and can be done most easily during the child’s bath. Place children in quiet environment to promote adequate rest. Parents need to understand that irritability is a hallmark of KD and need not feel guilty or embarrassed about child’s behavior. • Rheumatic fever: Diagnostic evaluation, teaching and ASO titers  Rheumatic fever is an inflammatory disease that occurs after pharyngitis caused by A B-hemolytic streptococci (GABHS). There is no single symptom or lab test to diagnose RF.  Major Manifestations: Carditis, polyarthritis, chorea, erythema marginatum & subcutaneous nodules.  Minor Manifestations: clinical findings include arthralgia & fever.  Lab findings include elevate erythrocyte sedimentation rate and C-reactive protein.  Teaching: Explain necessity for prophylactics, Antibiotics taken either orally or IM, IM penicillin G each month, Prophylactic antibiotics prior to dental work, important to prevent reoccurrence since very susceptible to reoccurrence, Teach parents to give PCN every day, Teach parents to report signs of infection, chorea will go away  Antistreptolysin (ASLO) titers measure the concentration of antibodies formed in the blood against this product (streptolysin O is a streptococcal extracellular product that produces lysis of the red blood cell). Normally the titers begin to rise about 7 days after onset of the infection and reach maximum levels in 4 to 6 weeks. Therefore a rising titer demonstrated by at least two ASLO tests is the most reliable evidence of recent streptococcal infection. Normal values are between 0 and 120 Todd units. Elevations over 333 Todd units indicate recent streptococcal infections in children • Blood pressure recommendations: age to start and intervals  BP determination should be a routine part of annual assessment in all children older than 3 years of age. Before a diagnosis of hypertension is made, measure BP in the sitting position on at least 3 separate occasions. • Supraventricular tachycardia – care of and initial actions pg. pg.  Treatment of SVT depends on the degree of compromise imposed by the dysrhythmia. In some instances, vagal maneuvers, such as applying ice to the face, massaging the carotid artery (on one side of the neck only), or having an older child perform a Valsalva maneuver (e.g., exhaling against a closed glottis, blowing on the thumb as if it were a trumpet for 30 to 60 seconds), can reverse the SVT. When vagal maneuvers fail, adenosine may be used to end the episode of SVT by impairing AV node conduction. IV adenosine is the first-line pharmacologic measure for termination of SVT in infants and children in the emergency setting. Adenosine must be given by rapid IV push with a saline bolus immediately following the drug. Incrementally increasing doses given about 2 minutes apart may be needed. The desired effect usually occurs in 10 to 20 seconds. Synchronized shock with a defibrillator is also used for cardioversion for patients that are hemodynamically unstable with a tachyarrythmia such as SVT with a palpable pulse, or electively in patients with hemodynamically stable SVT, under the direction of a pediatric cardiologist. Traditional first-line medical management of chronic SVT includes digoxin. If the infant or child is minimally symptomatic, digitalization can be initiated, with careful monitoring of vital signs and patient response to the intervention. More aggressive pharmacologic treatment with medications such as propranolol or amiodarone may be needed for those with more severe symptoms or recurrence of SVT while digoxin is being taken. If cardiac output is significantly compromised or signs of HF exist, esophageal overdrive pacing or synchronized cardioversion can be employed in the intensive care setting.  Care: A primary focus of nursing care is education of the family regarding the symptoms of SVT and the treatment. SVT may occur again despite therapy. After the first episode of SVT, parents should learn to take a radial pulse for 1 full minute. If medication is prescribed, instructions regarding accurate dosage and the importance of administering the correct dose at specified intervals are stressed • Signs and symptoms of shock Clinical signs Hypovolemic shock Distributive shock Cardiogenic Shock Obstructive Shock Respiratory rate Normal to increased Normal to increased Labored Labored Breath sounds Normal Normal (crackles may/may not be present) Crackles, grunting Crackles, grunting Systolic BP Compensated- normal Compensated- normal Hypotensive-low Hypotensive-low Pulse Pressure Narrow Variable Narrow Narrow Heart Rate Tachycardia Tachycardia Tachycardia Peripheral pulses Weak Bounding or weak Weak Skin Pale or cool Warm or cool Pale, cool Capillary refill Delayed ( 2 secs) Variable Delayed ( 2 secs) Urine output Decreased (1 ml/kg/hr [30 kg; 66 lb); 30-50 ml/kg/hr [30 kg, 66 lb]) Decreased (1 ml/kg/hr [30 kg; 66 lb); 30-50 ml/kg/hr [30 kg, 66 lb]) Decreased (1 ml/kg/hr [30 kg; 66 lb); 30-50 ml/kg/hr [30 kg, 66 lb]) Decreased (1 ml/kg/hr [30 kg; 66 lb); 30-50 ml/kg/hr [30 kg, 66 lb]) Level of consciousness Irritable early Late, lethargic • Preparation of the child undergoing cardiac surgery The expected outcomes for preprocedure preparation include reducing anxiety, improving patient cooperation with procedures, enhancing recovery, developing trust with caregivers, and improving long-term emotional and behavioral adjustment following procedures. The most beneficial preparation strategies usually combine information giving and training in coping skills such as conscious breathing exercises, distraction techniques, guided imagery, and other behavioral interventions. Handling preoperative and precatheterization workups on an outpatient basis is common for most elective procedures. For young children, bringing a familiar stuffed animal or comfort object with them will help relieve anxiety, whereas for older children bringing a music player with headphones and favorite recordings to the catheterization laboratory will help distract them during the procedure. Topics to discuss regarding recovery after catheterization include the need to lie still to prevent bleeding at the catheter site, progression of the diet, pain control measures, and monitoring methods. Review the importance of ambulation, coughing and deep breathing, and drinking and eating after surgery, and describe pain management and monitoring routines. Review simple coping strategies for use during painful procedures, including distraction techniques such as counting, blowing, singing, or telling stories • Topics to Include in Discharge Teaching After Cardiac Surgery  Medication teaching  Activity restrictions  Diet and nutrition  Wound care (include dressings if any, suture removal, bathing)  Infective endocarditis (bacterial) prophylaxis  Follow-up appointments (cardiologist, primary care provider)  Contact information for community agencies as needed (visiting nurse service, early developmental intervention)  Circumstances in which to call practitioner; signs and symptoms of postoperative problems  Review of cardiac defect and surgical repair Gastrointestinal concepts Chapter 33: • Review celiac disease and foods to avoid, foods that are OK  Treatment: of celiac disease consists primarily of dietary management. Although a gluten-free diet is prescribed, it is difficult to remove every source of this protein. Some patients are able to tolerate restricted amounts of gluten. Because gluten occurs mainly in wheat and rye, and in smaller quantities in barley and oats, these foods are eliminated. Corn, rice, and millet are substitute grain foods.  Children with untreated celiac disease may have lactose intolerance, especially if their mucosal lesions are extensive. Lactose intolerance usually improves as the mucosa heals with gluten withdrawal. Specific nutritional deficiencies, such as iron, folic acid, and fat-soluble vitamin deficiencies, are treated with appropriate supplements.  Foods to Avoid: In addition to restricting gluten, other dietary alterations may be necessary. For example, in some children who have more severe mucosal damage, the digestion of disaccharides is impaired, especially in relation to lactose. Therefore, these children often need a temporarily lactose-free diet, which necessitates eliminating all milk products. In general, dietary management includes a diet high in calories and proteins, with simple carbohydrates such as fruits and vegetables, but low in fats. • Signs and symptoms of rotavirus pg. 1091 pg. 1059  Diagnosis: EIA; Incubation 48 hours. Fecal oral transmission. 7 groups (A-G)—Most group A virus replicates in mature villus epithelial cells of small intestine; leads to (1) imbalance in ratio of intestinal fluid absorption to secretion and (2) malabsorption of complex carbohydrates. Mild to moderate fever: vomiting followed by onset of watery stools, fever and vomiting generally abate in approximately 2 days, but diarrhea persists 5-7 days. Immunocompromised children at greater risk for complications. Peak occurrences in winter months. Important cause of nosocomial infections.  S/S of Rotavirus: 1st fever with vomiting then diarrhea • Signs and symptoms of appendicitis vs. ruptured appendix pg. pg.  S/S of Appendicitis: right lower quadrant abdominal pain, fever, rigid abdomen, decreased or absent bowel sounds, vomiting (typically follows onset of pain), constipation or diarrhea, anorexia, tachycardia; rapid, shallow breathing, pallor, lethargy, irritability, stooped posture.  S/S of Ruptured Appendix: Signs of peritonitis in addition to fever usually include sudden relief from pain after perforation; subsequent increase in pain, which is usually diffuse and accompanied by rigid guarding of the abdomen; progressive abdominal distention; tachycardia; rapid, shallow breathing as the child refrains from using abdominal muscles; pallor; chills; irritability; and restlessness.  Management of Ruptured appendix: Management of the child diagnosed with peritonitis caused by a ruptured appendix often begins preoperatively with IV administration of fluid and electrolytes, systemic antibiotics, and NG suction. Postoperative management includes IV fluids, continued administration of antibiotics, and NG suction for abdominal decompression until intestinal activity returns. Sometimes surgeons close the wound after irrigation of the peritoneal cavity. Other times, they leave the wound open (delayed closure) to prevent wound infection. The treatment of a localized perforation with an appendiceal abscess is controversial. Some surgeons prefer to treat these children with antibiotics and IV fluids and allow the abscess to drain spontaneously. An elective appendectomy is then performed 2 to 3 months later. • Review Gastro-esophageal reflux (GER) positioning, feeding, baby formula additions pg.  Infants who are prone to develop GER include premature infants and infants with bronchopulmonary dysplasia. Children who have had tracheoesophageal or esophageal atresia repairs, neurologic disorders, scoliosis, asthma, cystic fibrosis, or cerebral palsy are also prone to develop GER. During infancy the most common clinical manifestation of GER is passive regurgitation.  Symptoms: Heartburn, abdominal pain, noncardiac chest pain, chronic cough, dysphagia, nocturnal asthma, recurrent pneumonia.  Avoidance of certain foods that exacerbate acid reflux (e.g., caffeine, citrus, tomatoes, alcohol, and peppermint, spicy or fried foods) can improve mild GER symptoms. Lifestyle modifications in children (e.g., weight control if indicated; small, more frequent meals) and feeding maneuvers in infants (e.g., thickened feedings, upright positioning) can help as well.  Feedings thickened with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula may be recommended. This may benefit infants who are underweight as a result of GERD; 1077however, the additional calories are not beneficial among infants who are overweight. These infants may benefit from pre-thickened formulas that are now commercially available. Constant NG feedings may be necessary for the infant with severe reflux and failure to thrive until surgery can be performed. Elevating the head of the bed and weight loss, if applicable, can reduce GER symptoms. Prone positioning of infants also decreases episodes of GER but is recommended only with extreme caution when the risk of GERD complications exceeds the risk of sudden infant death syndrome • Review tracheo-esophageal fistula signs, symptoms and immediate treatment  The esophagus develops from the first segment of the embryonic gut. During the fourth and fifth weeks of gestation, the foregut normally lengthens and separates longitudinally. Each longitudinal portion fuses to form two parallel channels (the esophagus and the trachea) that are joined only at the larynx. Anomalies involving the trachea and esophagus are caused by defective separation, incomplete fusion of the tracheal folds after this separation, or altered cellular growth during embryonic development.  The presence of EA is suspected in a newborn with frothy saliva in the mouth and nose, drooling, choking, and coughing. Respiratory distress may be mild or significant, depending on the type of defect and the infant's gestational age. If fed, the infant may swallow normally but suddenly cough and gag, with return of fluid through the nose and mouth. The infant may become cyanotic and apneic because of aspiration of formula or saliva.  In the infant who has EA with a distal TEF (type C), the stomach becomes distended with air, and thoracic and abdominal compressions (especially during crying) cause the gastric contents to be regurgitated through the fistula and into the trachea, producing a chemical pneumonitis. When the upper segment of the esophagus opens directly into the trachea (types B and D), the infant is in danger of aspirating any swallowed material. Cyanosis or choking during feeding may be the only symptom of type H fistula. The child with this type of EA may not manifest symptoms until later in life when he or she shows signs of chronic respiratory problems, recurrent pneumonia, and signs of gastroesophageal reflux.  Nursing Interventions: suction mouth and nose as necessary to clear mucus, place infant in best position to facilitate drainage of secretions, monitor airway patency. Monitor vital signs, including pulse oximetry, administer oxygen as needed per unit protocol. Keep NPO until cause of distress is determined. Insert double-lumen NG and attach to gravity drainage or low suction. Establish peripheral intravenous access. • Differences in signs and symptoms between Crohn’s disease and Ulcerative Colitis CHARACTERISTICS ULCERATIVE COLITIS CROHN DISEASE Rectal bleeding Common Uncommon Diarrhea Often severe Moderate to severe Pain Less frequent Common Anorexia Mild or moderate May be severe Weight loss Moderate May be severe Growth retardation Usually mild May be severe Anal and perianal lesions Rare Common Fistulas and strictures Rare Common Rashes Mild Mild Joint pain Mild to moderate Mild to moderate • Short bowel syndrome: total parenteral nutrition & use of enteral nutrition pg. pg.  Most common cause of SBS in children are necrotizing enterocolitis, volvulus, jejunal atresias, and gastroschisis. The definition of SBS includes two important findings: (1) decreased intestinal surface area for absorption of fluids, electrolytes, and nutrients; and (2) a need for parenteral nutrition (PN).  Nutritional support is the long-term focus of care for children with SBS. The initial phase of therapy includes PN as the primary source of nutrition. The second phase is the introduction of enteral feeding, which usually begins as soon as possible after surgery. Elemental formulas containing glucose, sucrose and glucose polymers, hydrolyzed proteins, and medium-chain triglycerides facilitate absorption. Usually these formulas are given by continuous infusion through an NG or gastrostomy tube. As the enteral feedings are advanced, the PN solution is decreased in terms of calories, amount of fluid, and total hours of infusion per day. If enteral feedings are tolerated, oral feedings should be attempted to minimize oral aversion and preserve oral skills.  The final phase of nutritional support occurs when growth and development are sustained. When PN is discontinued, there is a risk of nutritional deficiency secondary to malabsorption of fat-soluble vitamins (A, D, E, and K) and trace minerals (iron, selenium, zinc). • Lead poisoning: signs and symptoms, treatment of lead poisoning  Clinical manifestations: There is a relationship between anemia and lead poisoning. Children who are iron deficient absorb lead more readily than those with sufficient iron stores. Lead can interfere with the binding of iron onto the heme molecule. This sometimes creates a picture of anemia, even though the child is not iron deficient. Lead toxicity to the erythrocytes leads to the release of the enzyme erythrocyte protoporphyrin (EP). Acute signs of lead poisoning include nausea, vomiting, constipation, anorexia, and abdominal pain. Additional clinical manifestations are hypophosphatemia, glycosuria, and aminoaciduria.  Low-dose exposure: distractibility, impulsivity, hyperactivity, hearing impairment, mild intellectual deficits.  High-dose exposure: Lead encephalopathy (cognitive impairment), paralysis, blindness, convulsions, coma, and death.  Therapeutic Management: The degree of concern, urgency, and need for medical intervention changes as the lead level increases. Education is one of the most important elements of the treatment process. Several areas that the nurse needs to discuss with the family of every child who has an elevated BLL (≥5 mcg/dl).  The child's BLL and what it means  Potential adverse health effects of an elevated BLL  Sources of lead exposure and suggestions on how to reduce exposure, such as importance of wet cleaning to remove lead dust on floors, windowsills, and other surfaces  Importance of good nutrition in reducing the absorption and effects of lead; for persons with poor nutritional patterns, adequate intake of calcium and iron and importance of regular meals  Need for follow-up testing to monitor the child's BLL  Results of an environmental investigation if applicable  Hazards of improper removal of lead paint (dry sanding, scraping, or open-flame burning)  Chelation Therapy: Chelation is the term used for removing lead from circulating blood and, theoretically, some lead from organs and tissues. Although not an antidote in the truest sense, it does serve a similar purpose in that the toxic substance or poison is removed from the body. However, chelation does not counteract any effects of the lead.  Three chelating agents have been used consistently: calcium disodium edetate (CaNa2EDTA, or calcium EDTA), British antilewisite (BAL, dimercaprol, dimercaptopropanol), and Meso-2,3-dimercaptosuccinic acid (DMSA, chemet, Succimer). British antilewisite (BAL, dimercaprol, dimercaptopropanol) is used in conjunction with calcium EDTA with high lead levels or the presence of lead encephalopathy. All the agents have potential toxic side effects and contraindications. Renal, hepatic, and hematologic parameters should be monitored.  Adequate hydration is essential during therapy because the chelates are excreted via the kidneys.  Severe lead toxicity (lead level ≥70 mcg/dl) requires immediate inpatient treatment, whether symptoms are present or not. BAL is contraindicated in children with peanut allergies or hepatic insufficiency. Also, use with caution in children with renal impairment or hypertension; monitor for hemolysis with presence of glucose 6-phosphate dehydrogenase deficiency. BAL should not be given in conjunction with iron. BAL is administered as a deep intramuscular injection, in repeated doses over several days. Calcium EDTA may be administered intravenously or intramuscularly (in a different site from BAL); begin with second BAL dose. The intravenous route should not be used in children with cerebral edema.  For lead levels of 45 to 69 mcg/dl and an absence of symptoms, DMSA can be used. DMSA is given orally over a 19-day course of treatment. The capsule can be opened and sprinkled on a small amount of food or may be swallowed whole. DMSA can be used in conjunction with iron. Adverse effects include nausea, vomiting, diarrhea, loss of appetite, rash, elevated liver function tests, and neutropenia. Because the chelates are excreted via the kidneys, adequate hydration is essential. • Cleft lip and palate feeding, post op care pg.426-432 pg. 302-306  Feeding: Begin by positioning the infant upright with the head supported by the caregiver's hand or cradled in the arm. This position helps gravity to direct the flow of liquid so that it is swallowed rather than entering into the nasal cavity.  The Special Needs Feeder also has a long nipple chamber that can be compressed by the feeder for additional support. It comes in regular and mini nipple sizes, and also has a slit-cut tip, which the feeder can rotate within the baby's mouth to allow for increased or decreased flow of liquid. The Pigeon bottle has a wide, bulbous nipple and Y-cut tip, which allows for a faster flow of liquid.  These infants should be burped following every ounce of liquid, or two to three times during a feeding. Additionally, they often have some degree of liquid that enters the nasal cavity during the feed, which may alarm the feeder who is not used to feeding babies with clefts. An indication that the infant needs to stop feeding momentarily is the facial signal, which involves elevated eyebrows, a wrinkled forehead, or watery eyes; the nipple may be gently removed to allow the infant to swallow formula in the mouth without getting upset.  Postoperative Care: Cleft Lip and Palate  Cleft Lip: The major efforts in the postoperative period are directed toward protecting the operative site. Avoid the prone position to prevent suture damage. After CL repair (cheiloplasty), some surgeons allow the infant to return to breastfeeding or bottle-feeding, while others require syringe-feeding once the child is awake and alert. Elbow restraints may be applied after surgery to prevent the infant from rubbing the suture line.  Avoid the use of suction or objects in the mouth such as tongue depressors, thermometers, spoons, or straws.  Cleft Palate: The child should be closely observed postoperatively for signs of airway obstruction, hemorrhage, and laryngeal spasm. A face mask is often used to deliver oxygen. A tongue stitch may be used to prevent the tongue from obstructing the airway; it is taped to the cheek and may be removed per surgeon's preference. Observe the child's vital signs and oxygen saturation for potential airway compromise. Signs of stridor, croup, or difficulty breathing and/or swallowing should be carefully evaluated. The child with a CP repair may be placed on clear liquids for 24 hours followed by a liquid diet for 2 weeks. A soft diet may be encouraged for a full 6 weeks following palate repair • Pyloric stenosis: post-operative care and feeding pg pg.  Occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric canal. This produces an outlet obstruction and compensatory dilation, hypertrophy, and hyperperistalsis of the stomach. This condition usually develops in the first few weeks of life, causing nonbilious vomiting, which occurs after a feeding; projectile vomiting may develop and the infant is fussy and hungry after vomiting. If the condition is not diagnosed early, dehydration, metabolic alkalosis, and failure to thrive may occur.  Therapeutic Management: The surgical procedure is often performed by laparoscope and consists of a longitudinal incision through the circular muscle fibers of the pylorus down to, but not including, the submucosa (pyloromyotomy, or the Fredet-Ramstedt operative procedure). The procedure has a high success rate. The use of a small incision for the laparoscope may result in a shorter surgical time, more rapid postoperative feeding, and shorter hospital stay.  Feedings are usually begun 4 to 6 hours postoperatively, beginning with small, frequent feedings of water or electrolyte solution. If clear fluids are retained, about 24 hours after surgery formula is started in the same small increments. The amount and the interval between feedings are gradually increased until a full feeding schedule is reinstated, which usually takes about 48 hours. Infants undergoing pyloromyotomy between 2 and 8 weeks of age are at higher risk for postoperative apnea as a result of CNS immaturity and anesthesia; such infants should be closely monitored for 24 hours prior to discharge • Intussusception signs and symptoms, assessment pg. pg. Intussusception occurs when a proximal segment of the bowel telescopes into a more distal segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction. As the edema from the obstruction increases, pressure within the area of intussusception increases. When the pressure equals the arterial pressure, arterial blood flow stops, resulting in ischemia and the pouring of mucus into the intestine. Venous engorgement also leads to leaking of blood and mucus into the intestinal lumen, forming the classic currant jelly–like stools. The most common site is the ileocecal valve (ileocolic), where the ileum invaginates into the cecum and then further into the colon.  S/S: Sudden acute abdominal pain, child screaming and drawing the knees onto the chest, child appearing normal and comfortable between episodes of pain, vomiting, lethargy, passage or red, currant jelly-like stools (stools mixed with blood and mucus), tender, distended abdomen, palpable sausage-shaped mass in upper right quadrant, empty lower right quadrant (Dance sign), Eventual fever, prostration, and other signs of peritonitis.  Assessment: Usually subjective findings alone; ultrasonography that reveals a characteristics heterogenous mass and a “bull’s eye”. A rectal examination reveals mucus, blood, and occasionally a low intussusception itself Burns Chapter 29: Immediate management of Major Burns – priorities pg. 1124 pg. 977 Treatment of burn shock and management of pulmonary status. Remember ABC’s? That’s very important. Capillary refill. Monitor vital signs, output, fluid infusion, and respiratory parameters are ongoing activities in the hours immediately after injury. Care of the burn wound is secondary to the more critical problems of respiratory and cardiac failure. IV infusion begins immediately and is regulated to maintain a urinary output of at least 1 to 2 ml/kg in children weighing less than 30kg • Burn phases: Acute, management, rehabilitation pg. 984  Acute phase: The primary emphasis during the emergent phase is the treatment of burn shock and management of pulmonary status. Monitoring vital signs, output, fluid infusion, and respiratory parameters are ongoing activities in the hours immediately after injury. IV infusion begins immediately and is regulated to maintain a urinary output of at least 0.5 to 1 ml/kg in children weighing less than 30 kg (66 lb). Expect an output of 30 to 50 ml/hr in children weighing more than 30 kg. Urinary output and specific gravity, vital signs, laboratory data, and objective signs of adequate hydration guide the rate of fluid administration. They require constant observation and assessment, with special attention given to signs of respiratory, cardiac, and renal complications. Alterations in electrolyte balance can produce clinical symptoms of confusion, weakness, cardiac irregularities, and seizures. Changes in respiratory function and gas exchange are reflected clinically by restlessness, irritability, increased work of breathing, and alterations in blood gas values. The loss of the skin's protective function exposes burned children to an increased risk of hypothermia.  Management Phase: Begins after the patient's condition is stabilized. The multidisciplinary team concentrates on preventing wound infections, closing the wound as quickly as possible, and managing the numerous complications that may occur.  Rehabilitation Phase: Begins when permanent wound closure has been achieved, rehabilitation issues are identified on admission and are included in the care plan throughout the hospital course • Rehabilitative phase (long term)- care of burn wounds & complications to avoid pg. 1129 pg. 989  Exposure—Wounds are left open to air; crust forms on partial-thickness wounds, and eschar forms on full-thickness burns.  Open—Topical antimicrobial agent is applied directly to the wound surface and the wound is left uncovered.  Modified—Antimicrobial is applied directly or impregnated into thin gauze and applied to the wound; gauze or net secures the area.  Occlusive—Antimicrobial is impregnated in gauze or applied directly to the wound; multiple layers of bulky gauze are placed over the primary layer and secured with gauze or net. Occlusive methods may impede joint movement due to bulky gauze wraps. Advantages include reduction of evaporative heat loss from the wound, comfort, and protection.  Complications: o Pulmonary System: Inhalation injury, aspiration of gastric contents, bacterial pneumonia, pulmonary edema and insufficiency, and emboli o Wound Sepsis o Gastrointestinal System: feeding intolerance, mucosa ulceration, and bleeding o Central Nervous System: encephalopathy: lethargy, withdrawal, or coma; rarely delirium and transient psychosis • Types of wound dressings to prevent scarring Jobst Compression dressings, Integra: artificial skin, • Care and treatment of pediatric patients with burns and complications of burns  Treatment: Closing the wound is the primary goal of burn wound care. The nurse has a major responsibility for cleansing, débriding, and applying topical medications and dressings to the burn wound. Because dressing removal is a painful procedure, children should receive adequate analgesia before the scheduled dressing change. The nurse should administer medication so that the drug's peak effect coincides with the procedure. Distraction therapy, deep breathing, and relaxation techniques may facilitate the procedure. Most children also benefit from parental participation. Medical play is often effective in helping the younger child gain some mastery over the procedure. Outer dressings are removed; any dressings that have adhered to the wound are easier to remove by applying tepid water. Loose or easily detached tissue is also débrided during the cleansing process. Encourage children to participate in dressing removal. Giving them something constructive to do helps them focus on something other than the procedure. In dressing the wound, it is important that all areas be clean, that medication be amply applied, and that no two burned surfaces touch each other (e.g., fingers or toes, or ears touching the side of the head). If touching, the burned surfaces will heal together, causing deformity or dysfunction. Topical medications are applied directly to the wound with a clean gloved hand or impregnated into fine-mesh gauze before application. Then apply dressings to assist in exudate absorption, wound debridement, and increased patient comfort. All dressings applied circumferentially should be wrapped in a distal-to-proximal manner. Apply the dressing with sufficient tension to remain in place without impairing circulation or limiting motion. A stable dressing is especially important when the child is ambulatory. Another challenge for nurses is preventing graft loss. After a graft is applied in surgery, there is usually a period of immobility for the child. Positioning must be maintained in order to prevent graft loss from shearing forces of movement. Grafted joint areas may be splinted to maintain range of motion or prevent contracture formation, and this may cause discomfort. Dressings protect the grafts and must be monitored for increased drainage or odors that are signs of infection. The child must also be instructed not to pick under the dressings, which could result in graft loss or infection. Burns that involve the eyelids require special care to prevent corneal ulceration. No solution other than saline should come in contact with the eyes during the cleansing process. Avoid vigorous debridement in this area of thin, delicate tissue. Assess the patient throughout the healing process for the ability to close the eyes. Inability to close the eyes because of contracture formation, administration of paralytic agents, or corneal burns requires instilling ophthalmic ointment. A patch is not used over the affected eye, since it is not found to improve healing or reduce pain  Complications of Burns: Infections, shock, tachycardia, tachypnea, contractures, loss of function, scarring, and deformity. • Nutrition for burn patients pg. 1128 pg. 988 Oral feedings are common unless the child is intubated or paralytic ileus persists. Because children often lack appetite, the nurse must encourage, help and be patient with the child. Consultation between the parents and dietitian helps determine food preferences. Include children who are old enough to participate in meal planning. Children who require enteral supplementation by tube feeding must be monitored on an ongoing basis for intolerance and tube malposition. The nurse should monitor and record any indications of abdominal distention, diarrhea, or electrolyte and metabolic derangement. Accurate documentation of oral, parenteral, and enteral nutritional intake is essential to evaluate the adequacy of nutritional support • Burn pathophysiology  Thermal injury  Vasodilation  Increased hydrostatic pressure  Increased capillary permeability  Fluid loss – assess mentation, respiratory pattern & cap refill  Immediate threat to airway, potential for Genitourinary concepts Chapter 30: • Urinary tract infections: signs/symptoms, teaching, most common causes, labs(SATA) pg. 1144 pg.  S/S: Infants and toddlers under 2 years of age have nonspecific symptoms, such as fever, irritability, lethargy, poor feeding, vomiting, and diarrhea. Newborns may have fever, hypothermia, jaundice, tachypnea, or cyanosis, and they appear quite ill. The classic symptoms of UTI are often observed in children over 2 years of age. These include enuresis or daytime incontinence in the child who has been toilet trained, fever, foul-smelling urine, increased frequency of urination, dysuria, or urgency. Children may also complain of abdominal pain or costovertebral angle tenderness (flank pain). Some patients have hematuria or vomiting. Infants and young boys may develop obstructive-like symptoms, with dribbling of urine, straining with urination, or a decrease in the force and size of the urinary stream. High fever and chills accompanied by flank pain, severe abdominal pain, and leukocytosis suggest pyelonephritis. However, flank pain and tenderness may be the only indication of pyelonephritis on physical examination. Manifestations in older children and adolescents are more specific. Symptoms of lower tract infections include frequency and painful urination of a small amount of turbulent urine that may be grossly bloody. Fever is usually absent or low grade. Upper tract infection is characterized by fever (38° C), chills, and flank pain, often in addition to lower tract symptoms.  Teaching: Prevention is the most important goal in both primary and recurrent infection. Most preventive measures are simple, ordinary hygienic habits that should be a routine part of daily care. Investigate any signs of intestinal parasites (e.g., scratching between the legs and around the anal area) and treat them appropriately. Advise sexually active adolescent girls to urinate as soon as possible after intercourse to flush out bacteria introduced during sex. Perineal hygiene: wipe from front to back. Avoid tight clothing or diapers; wear cotton panties rather than nylon. Avoid “holding” urine; encourage child to void frequently, especially before a long trips. Encourage generous fluid intake.  Most Common Causes: Wiping front to back on females, urinary stasis, uncircumcised, over distention of the bladder, catheters, holding urine, poor hygiene, tight clothing or diaper  Labs/Diagnostic Evaluation (SATA): Urine with possible infection may appear cloudy, hazy, and thick, with noticeable strands of mucus and pus, it also may have an unpleasant odor. A presumptive UTI diagnosis can be made on the basis of microscopic examination of the urine, which often reveals pyuria (at least 10 white blood cells/ml of uncentrifuged urine) and the presence of at least one bacterium on Gram stain. However, a normal urinalysis may also be present in conditions of asymptomatic bacteriuria. The key to distinguishing true UTI from asymptomatic bacteriuria is the presence of pyuria • Wilm’s tumor assessment and care  S/S: The most common presenting sign is painless swelling or mass within the abdomen. The mass is characteristically firm, nontender, confined to one side, and deep within the flank. If it is on the right side, it may be difficult to distinguish from the liver, although, unlike that organ, it does not move with respiration. Parents usually discover the mass during routine bathing or dressing of the child.  Compression from the tumor mass, metabolic alterations secondary to the tumor, or metastasis. Anemia, usually secondary to hemorrhage within the tumor, results in pallor, anorexia, and lethargy. Hypertension, probably caused by secretion of excess amounts of renin by the tumor, occurs occasionally. Other effects of malignancy include weight loss and fever. If metastasis has occurred, symptoms of lung involvement, such as dyspnea, cough, shortness of breath, and pain in the chest, may be evident.  Therapeutic Management: Combined treatment with surgery and chemotherapy, with or without irradiation, is based on the clinical stage and histologic pattern. In unilateral disease a large transabdominal incision is performed for optimum visualization of the abdominal cavity. The tumor, affected kidney, and adjacent adrenal gland are removed.  If both kidneys are involved, the child may be treated with chemotherapy preoperatively to shrink the tumor, allowing more successful surgery (Davenport, Blanco, and Sandler, 2012). In some cases a partial nephrectomy is performed, followed with additional administration of chemotherapy. When additional therapy is not effective, bilateral nephrectomy is performed with obligatory dialysis and a renal transplant is pursued. • Diagnostic tests for G/U disorders Pain on urination, frequency, hesitancy, urgency, hematuria, nocturia, polyuria, unpleasant odor to urine, force of stream, discharge, change in size of scrotum, date of last urinalysis (for adolescent, sexually transmitted infection, type of treatment; for male adolescent, ask about testicular self-examination) • Vesicoureteral reflux  VUR refers to the retrograde flow of urine from the bladder into the upper urinary tract. Reflux increases the chance for febrile UTI but does not cause it. When bladder pressure is high enough, refluxing urine can fill the ureter and renal pelvis. This is identified most often at peak bladder pressure during voiding, but it can occur as the bladder fills and remain after voiding, even draining down into the bladder, leaving residual urine until the next void.  Therapeutic Management Medical therapy consists of continuous antibiotic prophylaxis (CAP), based on the assumption that this will result in sterile urine and that reflux of sterile urine does not cause renal damage. The most common antibiotics used for this purpose are trimethoprim and sulfamethoxazole, trimethoprim, or nitrofurantoin given once daily at bedtime. Amoxicillin is used in infants less than 2 months of age but is not otherwise used because of the increased likelihood of resistant organisms.  Surgical management of VUR corrects the anatomy at the insertion of the refluxing ureter into the bladder and consists of open surgical correction with reimplantation of the ureter(s) or endoscopic correction. Surgical intervention is indicated in patients who are unlikely to resolve their reflux and are at risk for renal scarring, including those with grade V reflux with scarring, grade V reflux over 6 years of age, and children who fail medical therapy. Again, families play a role in the decision, both in their preferences and their ability to follow through with recommendations. For example, a child with recurrent UTIs whose parents are not compliant with CAP may be a candidate for surgical correction regardless of the grade of reflux • Glomerulonephritis symptoms, care pg. pg.  Clinical Manifestations: Typically, affected children are in good health until they experience the antecedent infection. In some instances there is no history of an infection, or it is described as only a mild cold. The onset of nephritis appears after a latent period. Because the child appears well during this time, parents may not recognize the association. Initial signs of nephritic reaction include puffiness of the face, especially around the eyes (periorbital edema); anorexia; and the passage of cola-colored urine. The edema is more prominent in the face in the morning but spreads during the day to involve the extremities, genitalia, and abdomen. The edema is only moderate and may not be appreciated by someone unfamiliar with the child's normal appearance. The urine is cloudy, smoky brown, or what parents describe as resembling tea or cola, and it is severely reduced in volume. The child is pale, irritable, and lethargic and appears unwell but seldom expresses specific complaints. Older children may complain of headaches, abdominal discomfort, or dysuria. On examination there is usually a mild to moderate elevation in blood pressure compared with normal values for age, although severe hypertension may be present. Occasionally a child will have an onset with severe symptoms such as seizures from hypertensive encephalopathy, pulmonary and circulatory congestion, or hematuria in the absence of hypertension and edema.  Therapeutic Management: Management consists of general supportive measures and early recognition and treatment of complications. Children who have normal blood pressure and a satisfactory urinary output can generally be treated at home. Those with substantial edema, hypertension, gross hematuria, or significant oliguria are often hospitalized because of the unpredictability of complications. Short hospitalization is the rule in uncomplicated cases; prolonged hospitalization is required only for children with severely impaired renal function. • Minimal Change Nephrotic Syndrome (MCNS): diagnostic evaluation, symptoms and expected labs  The cause of MCNS (also known as idiopathic nephrosis, minimal lesion nephrosis, nil disease, childhood nephrosis, lipoid nephrosis, or uncomplicated nephrosis) remains obscure. A nonspecific illness, usually a viral upper respiratory tract infection, often precedes the manifestations by 4 to 8 days but is considered to be a precipitating factor rather than a cause.  Clinical Manifestations: Puffiness of the face, especially around the eyes, is apparent on arising in the morning but subsides during the day, when swelling of the abdomen, genitalia, and lower extremities is more prominent. Generalized edema (anasarca) may develop gradually or rapidly. Edema of the intestinal mucosa may cause diarrhea, loss of appetite, and poor intestinal absorption. The volume of urine is decreased, and it appears darkly opalescent and frothy. The child often has extreme skin pallor and may experience skin breakdown during periods of severe edema. The child may be irritable and more easily fatigued or lethargic but does not appear seriously ill. Weight loss from poor appetite and loss of protein is not uncommon, although it is often obscured by edema. Changes in the nails appear as white (Muehrcke) lines parallel to the lunula, which are caused by prolonged hypoalbuminemia. The blood pressure is usually normal or slightly decreased. The child is more susceptible to infection, especially cellulitis, pneumonia, peritonitis, or sepsis.  Diagnostic Evaluation: Massive proteinuria is reflected in urinary excretion of protein that often reaches levels in excess of 2 g/m2 of body surface/day, with relatively greater clearance of low-molecular-weight proteins. Hyaline casts from high protein levels and sluggish flow and oval fat bodies, as well as a few red blood cells, can be found in the urine of most affected children, although there is seldom gross hematuria. Specific gravity is high and proportionate to the amount of protein concentration. Total serum protein concentrations are reduced, with the albumin fractions significantly reduced (2 g/dl) and plasma lipids elevated. Serum cholesterol may be as high as 450 to 1500 mg/dl. Hemoglobin and hematocrit are usually normal or elevated, and the platelet count is high (500,000 to 1,000,000/mm3) as a result of hemoconcentration. Serum sodium concentration is usually low, approximately 130 to 135 mEq/L. Total calcium levels are low due to albumin binding, so ionized calcium is a more reliable measure of calcium levels • Acute renal failure (ARF): nutrition, treatment expected, medications to treat hyperkalemia  Nutrition: If the child is able to tolerate oral foods, concentrated food sources that are high in carbohydrates and fat but low in protein, potassium, and sodium may be provided. However, many children have functional disturbances of the gastrointestinal tract, such as nausea and vomiting. Therefore, the IV route is generally preferred, and nourishment usually consists of essential amino acids or a combination of essential and nonessential amino acids administered by the central venous route.  Treatment expected: The most effective management of ARF is prevention. The development of ARF is a known risk in certain situations. This should be anticipated and recognized, and adequate therapy should be implemented (e.g., fluid therapy for children with hypovolemia in conditions such as dehydration, burns, and hemorrhage).  Treatment of ARF is directed toward treatment of the underlying cause, management of the complications of renal failure, and provision of supportive therapy within the constraints imposed by the renal failure. Treatment of poor perfusion resulting from dehydration consists of volume restoration as described in the treatment of dehydration. If oliguria persists after restoration of fluid volume or if the renal failure is caused by intrinsic renal damage, the physiologic and biochemical abnormalities that have resulted from kidney dysfunction must be corrected or controlled. Central venous pressure monitoring is usually implemented.  Hyperkalemia Treatment: Hyperkalemia can be minimized and sometimes avoided by eliminating potassium from all food and fluids, by reducing tissue catabolism, and by correcting acidosis. o Calcium gluconate, 0.5 ml/kg, administered intravenously over 2 to 4 minutes with continuous ECG monitoring, exerts a protective effect on cardiac conduction. o Sodium bicarbonate, 2 to 3 mEq/kg, administered intravenously over 30 to 60 minutes, elevates the serum pH to cause a transient shift of extracellular fluid potassium into the intracellular fluid. However, there is a risk of hypocalcemia, tetany, and fluid overload. o Glucose, 50%, and insulin, 1 unit/kg, administered intravenously, accelerate glycogen synthesis, causing glucose and potassium to move into the cells. Insulin facilitates the entry of glucose into cells. 1) Administration of a cation exchange resin such as sodium polystyrene sulfonate (Kayexalate), 1 g/kg, administered orally or rectally, to bind potassium and remove it from the body. This requires time to be effective, and a sodium ion is exchanged for each potassium ion. This increased sodium concentration adds to the body fluids, which may contribute to fluid overload, hypertension, and cardiac failure. 2) Dialysis or continuous hemofiltration.