NURS 651 Exam 3 (Maryville) Includes: GU, MS, ID, Immunizations, Nutrition

UTI: Defintion - Includes bladder, (cystitis) urethera (urethritis) and kidney (pyelonephritis) Signs and symptoms of UTI - -Fever may be only sign infants a & young child -Older children=urinary symptoms ( new onset incontinence, dysuria, frequency, abdominal pain Risk factors of UTI - FEMALE, Uncircumcised male, GENETICS, (Anatomy), BOWEL/BLADDER Dysfunction, Obstruction, Catheterization, SEX, Reflux Exam for UTI - Temp, BP, abd exam for mass, tenderness. suprapubic or costovertebral tenderness, check external genitalia, eval lower back for signs of occult myelomeningiocele, check other sources for fever. UTI testing - -clean catch, cath, suprapubic UA *dipstick, urine culture. -+ leukocyte esterase=pyuria -+nitrate=bacteria *C/S -+100,000 colonies for dx; may treat 50,000 or greater UTI cal app to estimate probability of UTI (ages 2 -23 months) Indications for urine sample - Girls: 2-11 months of age temp 100.4 (non-black) 2-11 months of age temp of 102.2 OR the,p 100.4 and no other fever source identified. 12-24 months of age temp 102.2 (non black) 12-24 months of age 102.2 and no other source of fever identified. 24 months One or more of the following: dysuria, frequency, new onset incontinence, back pain, abdominal pain, fever of 102.2 and no other acute cause. Infant UTI - non specific symptoms or asymptomatic UTI symptom cluster - Newborn- irritability, poor feeding, diarrhea, fever, vomiting. jaundice, hypothermia, cyanosis, lethargy Infants//todlers/preschool: diarrhea, vomiting, fever, poor feeding, strong urine odor, irritability, poor weight gain, diaper rash Schoolage/adolescents; fever, vomiting, strong urine odor, urethral pain or suprapubic, dysuria, incontinence. UTI differential diagnosis - Chemical irritation (bubble bath) vulvovaginitis dysfunctional voiding acute abdomen ( appe, STD) Foreign body Sexual abuse Dysfunctional voiding related to constipation UTI specimen collection - Clean catch urine midstream (bagged specimen don't do it) Straight Cath for mod to severe symptoms Suprapubic aspiration: only when culture is urgently needed. ( + is 1000 colonies) _blood culture obtained for 12months and suspected sepsis Indications for radiology in UTI - -Symptoms of pyelonephritis regardless of age and gender -UTI in child 3 months -males with first infection and females with second infection. even if not pyelonephritis and child 3 months of age. UTI treatment - -IV ABX- newborns, infants, or older children with vomiting, severe symptoms systemic illness or unable to take fluids -ORAL- 10 day regimen, or 14 days with completed infection. UTI drugs - 1. Bactrim ( infants 2 months) TMP 8-10mg/kg.BID Recommended until sensitivities are back since most UTI are caused by E. coli. 2. Amoxicillin 30-40 mg/kg/day TID 3months 3. Augmentin 40mg/kg/day TID 4. Sulfisoxazole 150mg/kg/day QID 5. Cephalexin 50mg/kg/day TID 6. Nitrofurantin 5-7mg/kg/day in divided doses (ideal treatment for UTI due to highly concentrated in the urine, but less effective for systemic/renal infections as it does not concentrate well in blood) Follow up Urine cultures - -2nd culture at 72 hours after initiating treatment if symptoms are not rsolving -culture 1 week after completion of treatment when test of cure is indicated. Tanner staging female pubic hair - 1. No pubic hair (preadolescent) 2. little pigment straight hair, 3. Pigmented, straight medial border of labia sparse 4. pigment, curly, abundant but less than adult 5. lateral spread of hair, triangle 6. only occurs in 10% of women Tanner staging female breast development - 1. Preadolescent nipple elevation 2. Breast buds with areolar enlargement 3. Breast enlargement without separate contour with nipple. 4. Projection of areola and nipple as separate mount to breast 5. Adult breast with areola receding and nipple projection from breast Tanner staging genital maturity males - 1. preadolescent 2. enlargement of scrotum and testes scrotum reddens and roughens 3. penis lengthens 4. penis enlarges in glans and and width 4. adult size and shape Glomerulonephritis Treatment - inflammation of the glomeruli of the kidney Supportive treatment due to spontaneous resolution occurs 95% of the time. Course does not seem to be positively affected by steroids, etc. -Peak of oliguria and hypertension may need hospitalization for sodium/fluid restriction or and diuretics/antihypertensice. ABX only if cultures are positive. -gross hematuria presists for 1-2 weeks. Symptoms of pyelonephritis - fever, back or flank pain Symptoms of chronic renal failure (7 red flags) - 1.FTT 2. Chronic anemia 3. Complicated enuresis 4. Prolonged unexplained vomiting (a.m.) 5. Hypotension 6. Unusual bone disease 7. Poor school performance due to memory, HA, fatigue) Nephrotic Syndrome Management - Characterized by massive proteinuria, caused by glomerular damage. STEROIDS mainstay. Prednisone 2mg/kg/day max 60mg per day Second line - cyclosporin, cyclophosphamide, rituximab Infection is major complication of NS. hypospadias - abnormal congenital opening of the male urethra on the undersurface of the penis. Seen by deflected urinary stream. ( sometimes seen on scrotum, or band of tissue causing curvature of penis ( chordee). Differentials: ambiguous genitalia, female masulinizations. hydrocele - a fluid-filled sac in the scrotum along the spermatic cord leading from the testicles. Seen as painless scrotal swelling. Some associated with hernia. Enlarges as day goes on. variable in size. Infant how many wet diapers per day - neonate+ minimum of 6 times per day infant + 6-20 times per day Toddler/preschooler+ 8-14 times per day school age= 6-8 times per day adolescent like adult. Percentage of calories from protein per day - 5-30% of daily calories. Fat soluble vitamins - Vitamins A, D, E, and K, which are found in food containing fat. They're stored in the liver and body fat. The body draws on these stored vitamins when needed. -Temporary dietary deficiencies may not affect growth and development -Stable when heated during cooking - absorption in intestines. - low fat diet, malabsorption, or increased motility can cause fat soluble vitamin decifciency -Require bile for absorption Benefits of breastfeeding - Protects against infections Nutritionally complete More digestible Bonding Economic Disease protection Characteristics of human milk - Water Lipids Fat Proteins Carbohydrates Vitamins and Minerals Colustrum=immunoglobulins Transitional milk mature milk Differential diagnosis of food allergies - Other environmental allergens asthma immunodeficiency psychological reaction to feeding Malabsorption (celiac disease or CF) Lactose intolerance Chronic diarrhea Heiner syndrome - milk induced pulmonary disease with infiltrates should be suspected in infants and young children who have persistent pulmonary disease without a clear cause. metabolic conditions effect on nutrition - Diabetes, CF, hypothyroidism, hypoparathyroidism, congenital adrenal hypoplasia, PKU, lysosomal storage disorders, Caloric needs of a toddler - calories per day Estimated energy requirements (EER=89x weight of child in kg)-100 +20. 89 x 10kg child= 890-100=790=20=810 calories per day Recommended daily activity amount for children - 60 minutes per day of moderate to vigorous activity. Newborn muscle exam - 1. Birth History LGA, breech, traverse, anoxia 2. Delay in motor development 3. unusual movement ie. dragging legs while crawl 4. Hand dominance is infancy is a critical sign of weakness in opposite side. Newborn MS exam - Barlow ortlani Allis sign Trendelenburg Gower's Scoliosis Flat footed Bow legs knock knees turned in foot newborn reflexes MS ( Brachial Plexus Injury) - -Erb's palsy -absent bicep reflex with assymetric moro and tonic neck reflex on affected side. -limp wrist and hand on one side & absent grasp reflex. -Hand paralysis with normal shoulder movement. -Limited neck movement how to treat a sprain - rest, ice, compression, elevation growing pains - typical in 3 to 5 year old children or 8-12 yrs present at night and does not involve joints. They are usually bilateral and intermittent. Acetaminophen along with heat and massage at bedtime may be helpful. causes of growing pains - rapid growth, puberty, fibrositis, weather, psychologically factors. Differential diagnosis for growing pains ( diagnosis of exclusion) - trauma, infection, hematology causes, SCIFE, Osgood- schlatter, osteochondritis, Physical findings related to growing pains - USUALLY NONE! ( no trauma, good ROM, NO edema or erythema) juvenile rheumatoid arthritis diagnosis - Chronic illness affecting joints occurs before age 16. Synovial inflammation with swelling, pain, heat or decreased ROM. Severity range: mild 1 joint to severe symptoms in many joints. S/S: Fever, rash, lymphadenopathy, organomegaly, joint inflammation, swelling, pain limited ROM. DX: CBC anemia, leukocytosis, synovial fluid with WBC 10-20,000. RA factor only present in 15-20%.ANA +, Xray swelling of soft tissue Labs: CRP, ESR, serum ferritin, platelets, prolactin, ANA, Complement levels, Legg-Calve-Perthes Disease - -Intermittent Limp after exertion=pain -avascular necrosis of the femoral head Legg-Calve-Perthes Symptoms - -Pain in groin, anterior hip, or greater trochanter -sometimes referred pain. -Limited ROM -Atrophy of or hamstrings. Symptoms of scoliosis - Unequal shoulder height Unequal scapula prominence Unequal waist angles ie hip only touches 1 arm Unequal rib prominence and chest asymmetry Uneven pant or shirt length Skin sacral dimple, n Pain is usually not an issue until the deformity has progressed Adams Bending Forward Test (test used in the schools to help with observing curvature in the spine) Salter Harris - Classification of fractures of the growth plate and epiphyseal injuries Salter Harris - S=straight across Type I (through growth plate) A=above joint Type II (through GP & metaphysis) L=Lower or Below Joint Type III (through GP & epiphysis) T=Two or Through Type IV ( through all 3) E &R= "erased" growth plate or crush injury Type V Green stick fracture - incomplete fracture with angulation/bowing risk for repeat fracture common in forearm fx buckle fracture - Compression injury, the bone buckles rather than breaks reduction - procedure that restores a bone to its normal position Displaced fractures are characterized by: - 2 ends of the bone are not lined up angulated fracture - fracture in which the broken bone segments are at an angle to each other loss of alignment, change in bone length or rotation transverse fracture - bone break with fracture line straight across shaft of bone avulsion fracture - fragment of bone chipped away from the main bone effusion - accumulation of fluid on joint open fracture (compound fracture) - Broken bone has come through the skin Communiated fracture - bits and pieces more than 2 Oblique fracture line - a break at an angle Torus fracture - cortex buckles but does not break segmental fracture line - two separate breaks in the bone spiral fracture - bone has been twisted apart Intra-articular fracture - The fracture line crosses the articular cartilage and enters the joint Impaction fracture - bone fragments are driven into each other compression fracture - occurs when the bone is pressed together (compressed) on itself depression fracture - broken bone portion is pressed inward When to image potential fracture - Point tenderness Decreased ROM Inability to bear weight pain with ambulation deformity edema/bruising specific injury Describing fractures - Age, gender, mechanism of injury, soft tissue involvement. • Open or closed • Specific bone • Location • Type • Displacement • Angulation • Neurovascular status • Soft tissue status Plastic deformation fracture - Bowing. the bone is bent no more than 45 degrees Growth plate fracture - Susceptible to fracture weak point in pediatrics 30% cause growth disturbance Plastic deformation fracture - AKA bend fracture. Bone bent no more than 45 degrees.**** Closed reduction or surgery Growth plate fractures common in what age - girls 9-12 boys 12-15 Apophyseal avulsion fracture - fibrocartilage physes instead of the columnar cartilage. adolescent athletes does not interfere with growth found in osgood schlatter or Sinding larsen johnson stress fractures - overuse injuries accumulated microtrauma adolescents Females males Xrays won't show it for 1-2 weeks MRI more sensitive Fractures requiring immediate referral - Open Deformed/angulated Rotated Displaced FX with dislocation any neuromuscular compromise Joint/articular surface involvement Barlow maneuver - Checking for easy dislocation of hip *place your index and middle finger over the greater tronchanter. Gently push both knees together at midline downwards. Positive:"Clunk" sounds or palpating trochangter being displaced by the index/middle finger ortlani - abduct the hip with anterior pressure development dyplasia of the hip Galeazzi sign (knee height) - Knees flexed look for equal height the one that is lower is the potentially dislocated one. Look for symmetric hip abduction ( lying flat and pushing legs down to table flexed) equally. look for symmetric hip adductions ( lying flat pushing legs together in flexed position) - initial infant hip exam Barlow ( 1 hip at a time) - hold knee with 2 fingers, roll hip back and forth to see if you can move it out of socket. ortlani - abduct the hip with anterior pressure ( trying to put dislocated hip back into place) palm of examiners hand around knee putting thumb and pointer finger around hip. development dyplasia of the hip Subluxation - dislocation of a joint Dorsiflexion - bending of the foot or the toes upward Supination - Palm up Pronation - palm down Inversion - Turning the sole of the foot inward Eversion - turning outward Varus - bent inward towards midline of the body Valgus - bent away from midline of the body Proximal - Nearest point of attachment Distal - farthest from the point of attachment Flexion - Decreases the angle of a joint extension - increases the angle of a joint Hyperextension - extension beyond anatomical position ABduction - Movement away from the midline of the body aDduction - Movement toward the midline of the body Rotation - CIRCULAR MOVEMENT AROUND AN AXIS Circumduction - circular movement of a limb at the far end Torticollis - head tilt due to shortening or spasm of one sternomastoid muscle. Diff dx: CNS tumor, Cyst on spinal cord, ocular dysfunctions. Dx test: cervical xray, TX: stretching exercises Developmental Dysplasia of the hip - abnormal development of the hip joint found that is congenital, causing dislocation. Sx: fat rolls asymmetrical, abnormal leg length, AROM limited. Newborn instability without deformity. Limp at onset of walking. Tx: Can have spontaneous improvement in perinatal period) under 6 months pavlik harness if unstable. after 6 months surgical reduction. Tests: US (ultrasonogram), x-ray of hips, AROM testing of hips talipes equnovarus (club foot) - congenital foot deformity in which the foot is rotated internally at the ankle; also called clubfoot (teratogenic, congenital, positional) S/S: variable rigidity of foot, mid calf atrophy, mild hypoplasia of tibia, fibula and bones of foot. Diff Dx: Internal femoral or tibial torsion, metatarsus adductus, neuromuscular disorders. DX: Xray TX: Refer to ortho for serial casting with manipulation at birth Metatarsus adductus or varus - .marked by the middle bones of the foot pointing in toward the body. "toeing in" Pigeon toe gait in older child, no pain Diff DX: club foot, internal femoral/tibial torsion DX: PE, XRAy not needed unless checking for underlying congenital abnormalities or foot is unusually rigid TX: stretch forefoot in all planes of motion for 6 months, can do serial casting or bracing until age 2 in rigid deformity. tibial torsion - abnormal bowing internal or external of tibia S/S: toeing in when walking/running. Tripping or falling noticed. No pain. DX: observation, angle measurements TX: reassure parents most childcare have spontaneous correction with growth Genu varum (bowlegs) - Lateral bowing of tibia. normal up to age 18- g does not increase after walking. persistent beyond 3= blount disease (distrubance of medial proximal tibial growth plate)-- surgery DX: xray for extreme of unilateral bowing. TX: observation for unnecessary tx for mild to mod Genu valgum (knock knees) - affects MCL and causes joint instability and makes one more prone to injury xray for extreme valgum or persists past age 7 or unilateral involvement.