Exam 3 Study Guide

Musculoskeletal- 9 Questions

 Trauma

 Leading cause of death in children older than 1 year

 Unintentional injury (active)

 Child abuse injury:

 Bumps

 Bruises

 Breaks- 25-50% are abuse

 Burns

 Anything that happens in the Bathroom

 Stories don’t match up with ability

 Prevention of injury

 Assessment of trauma

 Level of consciousness (LOC)

 ABC’s

 Spinal cord injury immobilization

 EMS/BLS/ALS- “the scene is safe”

 Control bleeding

 Systemic assessment “head-to-toe”

 Immobilized Child

 Causes

 Congenital defects

 Neuromuscular conditions

 Prolonged mechanical ventilation and sedation

  Infection or injuries

 Kids will try to be mobile even when they can’t

 Physiological effects of immobilization

 Affects most body systems:

 Muscular system- PT important

 Skeletal system- passive range of motion

 Cardiovascular system- orthostatic intolerance, thrombus, and one more

 Respiratory system- supine position makes it hard to breath, increased risk of pneumonia

 Gastrointestinal system- decreased appetite, fecal impaction, decrease pain med

 Metabolism- small frequent meals

 Renal system- increase risk of UTI and kidney stones

 Integumentary system- risk for ulcers, frequent turning

 Neurosensory system

 Diminished environmental stimuli- Use play therapy

 Sensory deprivation- bored, isolated

 Altered perception of self and environment

 Increased feelings of frustration, helplessness, anxiety

 Depression, anger, aggressive behavior

 Developmental regression- especially in toddlers

 Developmental stages affected

 Behavioral changes develop

 Need for family support and home care assistance

 Child in a Cast

 Three major types:

 Upper extremity
  Lower extremity

 Spica

 The cast

 Constructed of gauze strips impregnated with plaster of paris or synthetic, lighter-weight,

water-resistant materials

 Extremities are checked for abrasions, cuts, or jewelry

 Tube of stockinet is stretched over area to be casted and bony prominences are padded with

cotton sheeting

 Allowed to air dry

 Cast care

 Observe digits for swelling or discoloration

 Check movement and sensation of visible digits

 Frequent rest with elevation

 Don’t allow limb to be dependent for >30 minutes

 Elevate arm or hand (in a sling)

 Elevate leg when sitting

 Nothing inside the cast

 Examine skin inside the cast

 Keep out of water

 Itchy- cool air, icepack, meds

 Report signs of ischemia immediately

 Five P’s of Ischemia

 Pain

 Pallor

 Pulse
  Paresthesia- tingling

 Paralysis

 Traction

 Purpose

 To realign bone fragments

 To provide rest for an extremity

 To help prevent or improve contracture deformity

 To correct a joint deformity

 To treat a dislocation

 To allow preoperative or postoperative positioning and alignment

 To provide immobilization of specific areas of the body

 To reduce muscle spasms

 Types of Traction

 Manual- used for uncomplicated fracture

 Skin- minimal displacement, don’t if skin is damaged

 Skeletal- applied with pin to skeletal used when need A LOT of traction; skull, spine, _____

*Never release skeletal traction* READ ON

 Traction Care (go back for my notes)

 Care for skin traction

 Assess straps and bandages for proper positioning

 Care for skeletal traction

 Frequently assess and clean pins

 Prevent skin breakdown

 Wash and dry skin at least daily

  Keep skin dry

 Encourage balanced diet and fluids

 Prevent Complications

 Note neurovascular changes

 Distraction

 The process of separating opposing bone to encourage generation of new bone in the created

space

 Used when limbs are of uneven length

 Amputation

 Can result from congenital defect, a traumatic loss, or surgically required because of a

condition i.e. osteosarcoma

 Traumatic amputation

 Potential for reattachment

 Stump care

 Phantom limb pain

 Mobilization Devices

 Orthotics and prosthetics

 Crutches, canes, and walkers

 Wheelchairs

 Fractures

 Treated differently than adults

 Bones are more pliable and porous

 Rapid healing

 Clinical manifestations

 Generalized pain, swelling, and tenderness

  Diminished functional use

 May be bruising, severe muscle rigidity, or crepitus

 Types of fracture

 Complete vs. incomplete

 Fracture lines can be transverse, oblique, or spiral

 Simple vs. compound

 Plastic deformation

 Buckle or torus

 Greenstick

 Epiphyseal injuries

 Emergency treatment of fractures

 Assess the extent of injury-5 Ps:

 Pain and Point of tenderness

 Pulse

 Pallor

 Paresthesia

 Paralysis

 Reassess neurovascular status

  Immobilize the limb

 Call EMS or transport to medical facility

 Diagnostic evaluation

 Radiography

 Management of fractures

 Reestablish alignment and length

 Retain alignment and length

 Restore function to the injures parts

 Prevent further injury

 Pain management

 Promote bone healing

 Fracture complications

 Circulatory impairment

 Nerve compression syndromes

 Compartment syndromes

 Physeal damage

 Nonunion

 Malunion

 Osteomyelitis

 Kidney stones

 Pulmonary emboli

 Injuries related to sports participation

 Acute injuries-fractures, sprains, strains, and contusions

 Overuse injuries-stress fractures, bursitis, tendonitis

 Exercise induced heat stress

 Female athlete triad

  Drug use

 Contusions

 Most common injury

 Damage to the soft tissue, subcutaneous structures, and muscle

 Escape of blood into tissues--ecchymosis—black-blue discoloration

 Swelling, pain, disability

 Most serious involve quadriceps

 Dislocations

 Occurs when force of stress on ligament is great enough to disrupt the normal position of the

opposing bone ends or the bone end and its socket

 Common in elbow, shoulder, or patella

 Pain increases with active or passive movement of the affected extremity

 Hip dislocation- potential loss of blood supply to head of femur

 Common in 1-4 year olds “nursemaid’s elbow”

 Sprains and stains

 A sprain is trauma to a joint so severe that a ligament is either stretched or torn by force

 May have associated damage to blood vessels, muscles, tendons, and nerves

 Presence of joint laxity as indicator of severity

 A strain is a microscopic tear to the musculotendinous unit

  Therapeutic Management

 RICE- rest, ice, compression, elevation

 ICES- ice, compression, elevation, support

 Ice immediately to resuce pain and edema

 Elevation facilitates venous return and reduces edema

 Torticollis

 “Wry neck”

 Congenital or acquired limited neck motion with neck flexed or tilted laterally to the affected

side

 Treatment consists of gentle stretching exercises

 Kyphosis and Lordosis

 Kyphosis is an abnormally increased convex angulation in the curvature of the thoracic spine

 Most common form is “postural”

 Can result from TB, arthritis, osteodystrophy, or compression fracture

 Lordosis is an accentuation of the lumbar curvature beyond physiologic limits

 May be secondary complication of trauma or idiopathic

 In obese children, abdominal fat alters center of gravity, causing lordosis

 Idiopathic Scoliosis

 Most common spinal deformity

 Multiple potential causes, most cases idiopathic

 Generally becomes noticeable after preadolescent growth spurt

 May have complaint of “ill-fitting clothes”

 Bracing

 Surgery

 Developmental Dysplasia of the hip (DDH)

 Hip abnormalities in which there is ashallow acetabulum, femoral head subluxation or

dislocation

 Diagnosed through Barlow and Ortolani maneuvers

 Newborn to 6 months, Pavlik harness is common

 Assess skin integrity

 Legg-Calve-Perthes Disease

 Self-limiting disorder in heich there is aseptic necrosis of the femoral head

 The cause of the disease is unknown

 Physical therapy

 Traction or surgery

 Slipped Capital Femoral Epiphysis

 Spontaneous displacement of the proximal femoral epiphysis in the posterior and inferior

direction

 Usually idiopathic

 Clinical manifestations

 Episode of trauma with acute displacement

 Gradual displacement without definite injury

  Intermittent displacement (or combination of all)

 Rest, no weight bearing initially

 Surgery in some cases

 Clubfoot

 Complex deformity of ankle and foot

 Treatment involves correction of the deformity, maintance of the correction until normal

muscle balance is regained, and follow-up observation to avert possible recurrence of the

deformity

 Osteomyelitis

 Inflammation and infectious process in the bone

 Results in bone destruction, abscess formation, and dead bone

 S&S are severe pain, fever, irritability, and tenderness with or without local signs of

inflammation. These begin abruptly and resemble symptoms of arthritis and leukemia

 Marked leukocytosis

 Tx is IV antibiotics

 Septic Arthritis

 Bacterial infection in a joint

 Affects knees, hips, ankles, and elbows

 S&S- severe joint pain, swelling, warmth of overlying tissue, and occasionally erythema

 Tx is IV antibiotics

 Osteogenesis Imperfecta

 Osteoporosis syndrome characterized by excessive fractures and bone deformity

 Commonly inherited as an autosomal dominant trait

 S&S- varying degrees of bone fragility, deformity, and fracture; blue sclerae; hearing loss;

and dentinogenisis imperfecta

 Primarily supportive care

  Drugs

 Bisphosphonate therapy with pamidronate, olpadronate, neridronate, or alendronate

 Promote bone density and prevent fractures

 Caution with handling to prevent fractures

 Juvenile Idiopathic Arthritis (JIA)

 Chronic childhood arthritis

 S&S include stiffness, swelling, and loss of motion in affected joints

 Onset is before 16 years of age

 Negative RF (rheumatoid factor) in 90% of cases

 May “burn out” and become inactive

 No cure

 JIA Management

 Goal is to control pain, preserve joint function, minimize effects of inflammation such as

joint deformity, and promote normal growth and development

 NSAIDS are first drugs used

 Ibuprofen, naproxen, and meloxicam

 DMARDs are next

 Methotrexate and sulfasazine

 Biologic agents also used

 Etanercept, infliximad, and adalimumab

 Glucocorticoids

 Physical management- PT and OT

 Surgery-synovectomy

 Relieve pain

 Diet and exercise

  Sleep and rest

 Encourage school attendance

 Encourage comfort measures and ADLs

 Educate child and family

 Systemic Lupus Erythematosus (SLE)

 Chronic multisystem autoimmune disease of the blood vessels and connective tissue

 Typically manifests between 10-19 years

 Cause is unknown

 Characterized by inflammation

 Symptoms variable and unpredictable

 Initial intermittent symptoms include fever, fatigue, weight loss, and arthralgia; rash is also

common

 SLE Management

 Supportive care

 Medications- anti-inflammatories and immunosuppressive agents

 Diet, exercise, rest

 Sun avoidance

 Family and patient education

 Social support

Neuromuscular Dysfunction

 Cerebral Palsy (CP)

 A disorder of posture and movement from static brain injury perinatally or postnatally, which

limits activity

 Most common permanent physical disability of childhood

 Brain insult or injury during developmental period may result in CP

 Delayed gross motor development is a universal manifestation of CP

  Possible signs of CP

 Motor

 Poor head control after age 3 months

 Stiff or rigid limbs

 Arching back/pushing away

 Floppy tone

 Unable to sit without support at 8 months

 Clenched fists after age 3 months

 Behavioral

 Excessive irritability

 No smiling by 3 months

 Feeding difficulties

 Persistent tongue thrusting

 Frequent gagging or chocking with feeds

 CP Management

 Mobilizing devices

 Surgery

 Medication

 Technical aids

 Physical therapy

 OT

 Speech therapy

 Education

 Recreation

 Hypotonia
  Diminished muscle tone and weakness

 “Floppy infant syndrome”

 Muscles feel atrophied when palpated, marked head lag, often have poor suck

 Common causes are cerebral trauma, perinatal hypoxia, or a neuromuscular disorder

 Spinal Muscular Atrophy

 AKA Werdnig-Hoffmann or SMA

 Characterized by progressive weakness and wasting of skeletal muscles caused by

degeneration of anterior horn cells

 Inherited as autosomal recessive trait

 Nursing care is similar to that of the immobilized patient

 Guillain-Barre’ Syndrome

 AKA infectious polyneuritis

 Uncommon acute demyelinating polyneuropathy with a progressive, unusually ascending

flaccid paralysis

 Mild influenza-like illness or sore throat usually precedes the paralysis

 Recovery of joint and muscle contractions

 Tetanus

 AKA lockjaw

 An acute, preventable, but sometimes fatal disease caused by clostridium tetani

 Characterized by painful muscular rigidity in the masseter and neck muscles

 Prevented with immunizations and boosters

 Botulism

 Food poisoning caused by ingestion of clostridium botulism

 Botulism toxin inhibits the release of acetylcholine at the neuromuscular junction

  S&S- blurred vision, diplopia, weakness, dizziness, difficulty speaking, vomiting, and

dysphagia; followed by descending paralysis and dyspnea

 For infants, present with constipation, generalized weakness, and cranial nerve defects

 Tx consists of immediate administration of botulism immune globulin intravenously

 Myasthenia Gravis (MG)

 S&S- general paralysis of the optic muscles with ptosis and diplopia; difficulty swallowing,

chewing, snd speaking; weakness and paralysis of all skeletal muscles

 More pronounced in evening

 Rest can relieve symptoms; stress and exercise worsen them

 Spinal Cord Injuries (SCIs)

 Causes- MVCs, sports injuries, birth trauma, and child abuse

 S&S- absence of reflexes at or below the cord lesion, flaccidity or limpness of involved

muscles, loss of sensation and motor function, and autonomic dysfunction

 Autonomic dysreflexia s&s- flushed face, sweating forehead, pupillary constriction, marked

hypertension, headache, and bradycardia

 Management of SCIs

 Respiratory care

 Cardiovascular care

 Temperature regulation

 Skin care

 PT

 Neurogenic bladder

 Bowel training

 Autonomic dysreflexia

 Evaluation and support

  Remobilization

 Physical rehabilitation

 Physical rehabilitation

 Psychosocial rehabilitation

 Sexuality

 Muscular Dystrophies

 Largest group of muscle disease in childhood

 Genetic origin with gradual degeneration of muscle fibers, progressive weakness, and wasting

of skeletal muscle

 All have increasing disability and deformity with loss of strength

 Tx is supportive

 Duchenne Muscular Dystrophy

 Most severe and most common

 Inherited as x-linked recessive trait

 Evidence of muscle weakness usually appears between age 3-5

 Typical waddling gait, frequent fall, Gower sign, and lordosis

 Loss of independent ambulation by 9-12 years

 Relentless progression until death from respiratory or cardiac failure

 No effective treatment

Renal Dysfunction

 Renal system and function

 Maintain body fluid equilibrium

 Responds to changes in internal environment

  Maintains equilibrium by forming urine, tubular reabsorption, and tubular

excretion

 Reabsorption- the transport of a substance from the tubular lumen to

the blood in surrounding tissues

 Secretion- transport in the opposite direction

 Excretion- the elimination of a substance from the body, in this case,

urine

 Produce erythropoietin stimulating factor

 Produce renin

 Genitourinary tract disorders

 Urinary Tract Infection (UTI)

 Urethra and bladder (lower urinary tract)

 Ureters, renal pelvis, calyces, and renal parenchyma (upper urinary tract)

 Sources: urinary stasis, urinary catheters, not using prevention methods,

anatomical problems, dysfunctional voiding problems

 Pyelonephritis- kidney infection

 Renal scarring

 UTI: S&S Under age 2:

 Failure to thrive

 Feeding problems
  Vomiting

 Diarrhea

 Abdomical distention

 Jaundice

 Fever

 Hypothermia

 Sepsis

 Frequent or infrequent voiding

 Constant squirming and irritability

 Strong-smelling urine

 Abnormal stream

 Persistant diaper rash

 Over age 2:

 Enuresis or daytime incontinence in toilet trained child

 Fever

 Strong-or foul-smelling urine

 Increased frequency of urination

 Dysuria

 Urgency

 Abdominal pain
  Flank pain

 Hematuria

 Vomiting

 Prevention of UTIs

 Wipe front to back

 Avoid tight clothing or diapers

 Cotton underwear (nylon traps moisture and prevents air

circulation=bacteria)

 Don’t “hold” urine (urine stasis)

 Generous fluid intake

 Urinate after intercourse

 High protein diets?

 Vesicoureteral Reflux (VUR)

 Retrograde flow of bladder urine into the ureters

 Congenital anomaly, sometimes obstruction

 Most common cause of pyelonephritis in children

 Renal scarring

 Conservative therapy used first

 Nursing goal = encourage compliance with medical therapy

  Breakout infections can occur even with continuous antibiotic

prophylaxis (CAP)

 Acute Glomerulonephritis (AGN)

 Immune complex disease

 Streptococcal, pneumococcal, and viral infections

 Most common of the noninfectious renal diseases in childhood

 Common features:

 Tea or cola colored, oliguria, hematuria, proteinuria

 Loss of appetite

 Water and sodium retention, periorbital edema, moderate edema

 Hypertension

 Circulatory congestion- hypervolemia

 Major complications

 Hypertensive encephalopathy, acute cardiac decompensation caused

by hypervolemia, and acute renal failure (ARF)

 Acute phase lasts 4-10 days but may persist for 2 or 3 weeks

 Signs of improvement

 Urinary output increase

 Weight decrease
 Nephrotic syndrome

 Most common glomerular injury in children

 Massive urinary protein loss

 Cause: glomerular injury from an unknown cause, secondary, or

recessive gene

 Viral respiratory infection

 Most common between 1-8 years

 Signs and symptoms

 Weight gain in a short period

 Periorbital edema upon rising

 Abdominal and lower exrimity edema in evening

 Labial or scrotal swelling

 Diarrhea

 Loss of appetite

 Decreased urinary output that appears frothy and darkly opalescent

 Extreme skin pallor

 Easily fatigued

 White lines in nails (muehrcke lines)

 Labs

 Urinary protein levels 2g/m2 of body surface or higher

  Serum protein levels are decreased

 Albumin decreased

 Renal biopsy = epithelial foot processes are fused to basement membrane

 Specific gravity is high

 GFR can be normal

 Treatment

 Goal = reduce protein loss, prevent and treat infections if present, reduce

edema, maintain nutrition, control metabolic abnormalities

 Low sodium diet (temporary)

 Steroid therapy

 Cyclophosphamide (Cytoxan) or chlorambucil (leukeran)

 Diuretics ( but not super common)

 Pneumococcal conjugate vaccine (PCV13, pneumococcal

polycaccharide vaccine (PPSV23), and antibiotics

 Nursing care

 Edema monitoring

 I/O, daily weight, monitor urine for albumin levels, measure

abdominal girth, depth of pitting

 Monitor for shock or infection

 Vitals, color/texture of skin

  Elevate and/or support edematous areas

 Prevent intertrigo (irritation between skin folds)

 Clean, dry, and protect skin folds by creating a barrier with cloth or

antiseptic powder

 Irritability and mood swings

 Due to disease state and steroid therapy

 Acute renal failure (ARF)

 Kidneys are suddenly unable to regulate the volume and composition of

urine in response to food and fluid intake and the needs of the body

 Pre-renal cause

 Dehydration, surgical shock, trauma

 Intrinsic causes

 Diseases that damage kidney structures

 Post-renal causes

 Obstructions/injuries

 Key features:

 Oliguria, azotemia (elevated urea, acidosis, and electrolyte

disturbances)

 Most effective management is prevention

 Treat underlying cause, manage complications

  Hyperkalemia

 Hypertension

 Metabolic acidosis

 Anemia

 Seizures and coma

 Cardiac failure

 Pulmonary edema

 Nurse care

 ICU admission likely

 Close, frequent monitoring and specialized equipment needed

 Dialysis or hemofiltration

 Monitor fluid and electrolyte balance

 Calcium gluconate, sodium bicarbonate, kayexalate, or glucose and

insulin

 Antihypertensives

 Fluid restrictions

 Listen to, reassure, and keep parents informed

 Chronic renal failure

 Causes by congenital renal and urinary trat malformations and VUR

  First signs may be fatigue, subtle pallor, and falling behind on growth

chart

 Overtime poor eating, N/V, “muddy” pallor, increased OR decreased

urination, bleeding, itching develops

 Towards the end HTN, CHF, pulmonary edema, confusion, seizures, and

coma

 Additional Problems

 Leads to biochemical abnormalities

 Metabolic acidosis

 Calcium and phosphorus disturbances lead to growth disturbance and

bone pain

 Delayed or absent sexual maturation

 Decrease in hormones (testosterogene, estrogen, progesterone, and

luteinizing hormone)

 Anemia

 Infectin such as pneumonia, UTI, septicemia

 End stage renal failure

 Retention of waste products, water, sodium

 Hyperkalemia

 Dialysis
  Separates colloids and crystalline substances in solution (blood) through

osmosis, diffusion, and ultrafiltration

 Indicated for life-threatening electrolyte imbalance, severe volume

overload, bilateral kidney diseases and bilateral kidney remaoval, GFR

less than 15

 Reserved for children in ESRF

 Requires the creaton of an access (grafts, fistula, or external access

devices) and special equipment, special training of nurse

 Hemodialysis

 Blood is circulated outside the body through artificial cellophane

membranes that permit a similar page of water and solutes

 More efffecient that Peritoneal dialysis

 Preferred for those with hyperkalemia or certain poisonings

 3 tiems a week, for 3-5 hour

 Paients advised to increase their amount of K, phosphorua, Na, and fluid

in their diet

 Peritoneal Dialysis (PD)

 Abdominal cavity acts as a semipermeable membrane

 Easier to learn, safe to perform, requires minimum equipment

  Indications: acute conditions, neonates, children with severe

cardiovascular disease, or those who are poor risks for vascular access

 Contraindications: recent abdominal surgery, peritoneal

adhesions/scarring

 Continuous Venovenous Hemofiltration

 Used in acute care settings

 Ideal for children with fluid overload from surgical procedures

 Commonly used for critically ill children who require volume-expanding

fluids such as hyperalimentation solution, albumin, or packed red cells

 Transplantation

 Preferred means of renal replacement therapy in pediatrics

 Two possible sources: living related donor or deceased donor

 Must be on antirejection medications for life

 Signs of possible rejecton: fever, swelling and tenderness over the

graft area, diminished urinary output, elevated BP, and elevated serum

creatine

 Immunosuppressant therapy

 Prednisone and tacrolimus or mychopenolate, antilymphocyte

globulin, or monoclonal antibodies

  Graft survival is 96%, 91%, and 86% from living donors at 1, 3, and 5

years post transplant (from deceased donors is 94%, 81%, and 80%)

The child with integumentary dysfunction

 Eczema (Atopic Dematitis)

 Dry, itchy

 Often symmetrical

 Erythema, vesicles/papules

 Weeping, ooxing, then crusts over

 Unaffected skin dry/rough

 Treatment

 Mild moisturizes often

 Vaseline, Sorbelene, and aqueous cream (Aquaphor)

 Mild soaps, clothing detergents

 Hydrocortisone creams, triamcinolone

 Bath water: no soap/bubbles, not hot water

 Wool is irritating to skin

 Keep fingernails short

 Impetigo

 Contagious bacterial infection

 MRSA, or Staph. Aureus

 Limit contact with weeping sore

 Handwashing

 Wash toys in soap and hot water

  Antibiotics

 Ringworm (dermatophytosis)

 Fungal infection

 Live ondead skin layers

 Tinea capitis: on scalp

 Tinea corporis: on body

 Pets can be source

 Pediculosis capitis (head lice)

 Visualize white eggs

 Base of hair shaft

 Behind ears

 Nape of neck

 Scratching head

 Do not spray insecticides

 Manually remove nits AND apply pediculocides

 Permethrin 1% cream rinse (Nix)

 Diaper dermatitis

 Caused by moisture, friction, chemicals

 Temporarily avoid cloth diapers

 Wipe urine from the skin

 Erythema- macules/papules- erosions/crusts

 Avoid talcum powder!

 Avoid hot air to area

 Burns

 Extreme heat or cold

 Chemicals

 Electricity

 Radiation

 Child abuse

 Burn wound severity

 Total body surface area (TBSA) effected

 Depth of injury

 Causative agent

 Body area involved

 Age

 Other injuries

 Superficial burn (1st degree)

 Partial-thickness burn (2nd degree)

 Full-thickness burns (3rd degree)

 Full-thickness burns (4th degree)

 Pathophysiology of burns

 Injury: Immediate direct cellular response

 Localized to the site of the burn

 Proteins can be denatured

 RBCs destroyed

 Fluid loss/shifts

 Hypovolemia

 Hemoconcentration

 Edema formation

 Circulatory status

 Thrombi developed

 Tissue ischemia and necrosis

 Injury: delayed response caused by dermal ischemia

 A systemic response:

 Cardiovascular system- decreased circulating volume, organ dysfunction

 Renal system- tissue breakdown, decreased circulating volume, high risk for renal

failure

 Gastrointestinal system- decreased bloodflow, ulcers, enterocolitis, intestinal

performation can occur. May become a source of sepsis later on in hospitalization

 Metabolism increased- starvation can occur

 Oxandrolone

 Amino acids: glutamine and arginine

 Neurendocrine system
  Adrenal, epinephrine, norepinephrine activity increased

 Anemia and metabolic acidosis

 Initial elevated hematocrit (Hct)

 Growth and development

 Complications of burns

 Pulmonary system

 Inhalation injury, aspiration, bacterial pneumonia, pulmonary edema and

insufficiency, and emboli

 Pneumonia- high mortality

 Wound sepsis

 Early signs: disorientation, fever, diminished bowel sounds, paralytic ileus

 Late signs: abnormally low temperature, decreased WBC, wound deterioration

and septic shock becomes present

 GI system

 Feeding intolerance, mucosa ulceration and bleeding

 Antacids, H2 receptors

 Constipation

 CNS

 Burn Encephalopathy (by lethargy, withdrawal, or coma)

 Caused by hyponatremia, hypovolemia, septicemia, and drug administration

 Psychotropic medications

 Compartment Syndrome
  Occurs when increased pressure within a muscle group called a compartment and

comprises the circulation and function of the tissues within that space

 Fasciotomy

 Escharotomy

 Management of minor burns

 Cleanse with mild soap and tepid water

 Debride wound

 Cover the wound with antimicrobial ointment

 Dress with gauze

 Administer tetanus booster as needed

 Major burns: Emergency care:

 ABCDE assessment (airway, breathing, circulaton, disability, exposure)

 Supplemental O2 and continuous O2 sat reading

 Intubation and ventilation

 Stop the burning process

 Large bore IV and rapid IVFs

 Urinary catheter and possible NG tube

 Pediatric considerations

 IVF resuscitaton more common in small burns than adults with small burns

 Venous access can be more difficult

 Larger body surface areas

 Urine output should be about 1ml/kg/hour

 If 50 kg or more use adult parameters (30-50 ml/hour)

  Hypoglycemia a possibility

 Pattern may indicate abuse

 Management of minor burns

 Establish and maintain adequate airway

 Fluid replacement therapy

 Goal: compensate for water and sodium losses, restore circulating volume,

provide adequate perfusion, correct of acidosis, and improve renal function

 Example: Parkland formula calls for 4 ml/kg body weight per percentage burn

TBSA

 Nutrition

 Medicaton

 Sedation- Morphine, fentanyl, versed

 Procedural pain- nitrous oxide, Propofol, ketamine

 Management of the burn wound

 Primary excision

 Wound hygiene/wound dressings

 Topical antimicrobial agents

 Silver sulfadiazine (thermazene), mafenide acetate (sulfamylon), and

bacitracin

 Temporary skin substitutes

 Synthetic skin coverings

 Artificial skin

 Permanent skin coverings

  Cultured epithelium

 Topical antimicrobial agents

 Exposure

 Wounds are left open to air

 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 in the gauze or applied directly

to the wound, not open to air

 Synthetic skin coverings

 Petrolatum dressing (xeroform)

 Synthetic silicone meshed products (biobrane)

 Hydocolloid dressing (DuoDERM)

 Transparent adhesive films (OpSite and tegaderm)

 Management of burns

 Acute phase

 Management and rehabilitative phase

 Comfort management

 Care of the burn wound

  Nutrition

 Prevention of complications: acute care

 Prevention of complications: long-term care

 Psychosocial support of the child and family

 Caring for the caregiver

 Prevention of burns

 Keep hot liquids out of reach

 Tablecloths and dangling appliance cords are a potential source of burns

 Electrical cords andoutlets should be childproofed

 Hot water thermostats at no more than 120 degrees

 Matches and lighters out of reach

 stop, drop, and roll!

Balance and imbalance of body fluids

 Distribution of body fluids

 Total body water (TBW)

 45-75% total body weight

 Fetus is composed primarily of water with little tissue substance

 Intracellular fluid

 Fluid within the cell

 Extracellular fluid

 Intravascular (contained within the blood vessels)

 Fluid between the cells (interstitial fluid)

 Transcellular (within specialized body cavities)

  Cerebrospinal, synovial, and pleural fluid

 Fluid Assessment

 Urinary output of 25-30 ml/hour in pediatrics

 Urine specific gravity

 Concentration of all chemical particles in the urine

 Normal range is 1.010-1.025

 Increased when dehydrated (more particles in urine)

 Other signs of hydration status

 Weight loss or gain

 Vital signs

 Capillary refill

 Lack of tears

 Conditions decreasing fluid requirements

 CHF

 Syndrome of inappropriate antidiuretic hormone (SIADH)

 Mechanical ventilation

 After surgery

 Oliguric renal failure

 Increased intracrainial pressure

 Conditions increasing fluid requirements

 Fever

 Vomiting, diarrhea

 High-output kidney failure

  Diabetes insipidus

 Diabetes ketoacidosis

 Burns

 Shock

 Tachypnea

 Radiant warmer (preterm infants)

 Phototherapy (infants)

 Postoperative bowel surgery

 Special population: infants

 Greater fluid requirements

 Larger turnover of water exchange

 Larger body surface area

 Higher metabolic rate

 Kidney function immature

 Physiological inability of their renal tubules to concentrate

 Is newborn premature or term?

 Poorly developed thirst mechanism

 Calculate daily fluid maintenance

 Body weight fluid per day

 0-10 kg = 100 ml/kg

 11-20 kg = 1,000 ml + 50 ml/kg for each kg >10 kg

 >20 kg = 1,500 ml + 20 ml/kg for each kg >10 kg

 The maximum total fluid volume per day is normally 2,400 ml

  Fluid of choice either:

 D5 ¼ NS + 20 meq/l Kcl or D5 ½ NS +20 meq/l Kcl

 The maximum fluid rate is normally 100 ml/hr

 0-10 kg: 4 ml/kg/hr

 10-20 kg: 40 ml/hr +2 ml/kg/hr

 >20 kg: 60 ml/hr + 1 ml/kg/hr

42 kg = 1,500 ml+ 640ml = 2,140

60 ml/hr + 42 ml/hr= 100 ml/hr

 Dehydration

 Total fluid loss > total fluid intake

 v/d, dka, extensive burns, nasogastric losses, or altered renal output

 types of fluid loss

 isotonic

 occurs when electrolyte and water deficits are present in approximately balanced

proportions

 Hypotonic- “watered down”

 The solvent is greater than the solute

 Let the cell absorb water causing it to swell

 Hypertonic- “concentrated”

 The solute is greater than the solvent

 Allows fluids out of the cell, shrinking the cells

 Degree of dehydration

 *Earliest signs*
  Tachycardia, dry skin and mucous membranes, sunken fontanels, signs of

circulatory failure, loss of skin elasticity, and prolonged cap refill time

 Mild= less than 35 IN OLDER CHILDREN OR 5% in infants

 Moderate= 3-6% in older children and 5-10% in infants

 Severe= more than 6% in older and more than 10% in infants

 Diarrhea

 Glucose intolerance

 Indicated by watery, explosive stools

 Fat malabsorption

 Indicated by foul-smeeling, greasy, bulky stools

 Diarrhea that develops after the introduction of cow’s milk, fruits, or cereal may

be related to protein intolerance or enzyme deficiency

 Electrolyte Maintenance

 Maintenance requirements for sodium and potassium

 Sodium: 2-3 meq/kg/24hr

 Potassium: 1-2 meq/kg/24 hr

 Chloride is usually adequatw if at leas

 Glucose

 Determine % of dehydration and type of dehydration

 Calculate 24 hour water needs

 Calculate 24 hour electrolyte needs

 Select an appropriate fluid

  Administer half the calculated fluid in the first 8 hours (subtract any boluses from this

amount)

 Administer the remainder over the next 16 hours

 Replace ongoing fluid loss as it occurs

 Oral rehydration solution (ORS)

 **Glucose-based ORS**

 Glucose: 13.5-20 g, NaCl: (2.6) 3.5 g, KCl: 1.5 g, Na citrate (Bi) : 2.9 g, Water 1 liter

 Indications:

 Diarrhea and dehydration especially in infants and old age.

 All cases of loss of body fluids in non-comatosed patients (moderate dehydration &

acidosis)

 Can make at home:

 3.5 g (1/2 tsp) table salt

 1.5 g (1 ¼ tsp) potassium chloride or potassium salt

 2.5 g (1/2 tsp) baking soda

 20 g (2 Tbsp) glucose or 8 tsp sugar

 Add the above ingredients together in 1 L of water

 ***Cereal -based ORS***

 Contain rice powder, glycine, or starch (as a source of glucose) instead of glucose

 Advantages:

 More effective in decreasing vomiting

 More effective in treating diarrhea than glucose-based ORS

 FYI: Glucose-based ORS → ↑ stool volume →increase diarrhea

  Shortens duration of illness

 More effective in treating diarrhea due to cholera

 Disadvantages:

 Not readily available to use

 Prepared by boiling

 Should be prepared fresh (fermented 8-12 h).

 Enzymes should be present (amylase, maltase) not for infants younger than 4 months

 Parenteral fluid therapy

 PFT used to prevent dehydration, electrolyte disorders, prevent ketoacidosis, and

prevent protein degradation

 Indications - Diarrhea

 Severe dehydration (> 10% of BW loss in infants)

 When diarrhea is accompanied by severe uncontrolled vomiting

 Inability to comply with oral fluids

 Indications: Other

 Hemorrhage

 Shock

 Electrolyte disturbances

 Supplying fluids and food for patients who are unable to maintain oral intake.

 Complications

 Infiltration

 Unintentional administration of a non-vesicant parenteral solution or medication into

surrounding tissue
  Extravasation

 Unintentional administration of a vesicant solution or medication into surrounding

tissue

 Phlebitis: mechanical, chemical, bacterial

 S/S of infiltration or extravasation

 Redness, pain, edema, blanching, streaking on skin along vein, darkened area at

insertion site

 Tx: immediately stop infusion, elevate extremity, and notify practitioner

 Etiology of vomiting

 Chronic or intermittent

 Color and consistency

 Associated symptoms

 Green, bile vomiting ?

 Curdled stomach contents, mucus, or fatty foods that are vomited several hours after

ingestion?

 Fever and diarrhea?

 Constipated?

 Forceful vomiting?

 Change in LOC or headache?

 Localized abdominal pain?

 Management of vomiting

 Priority

 Treat the underlying cause

  Prevent complications-dehydration and malnutrition

 Position patient to prevent aspiration

 Treatment

 Antiemetic drugs: Zofran, Tigan, Reglan, Phenergan

 What are contraindication? Side effects? Time of onset? How do they work

physiologically?

 Careful observation and assessment

Cardiovascular Dysfunction