EXAM

NOTES
Child with
Cardiovascular Dysfunction
-Kawasaki Disease= acute systemic vasculitis of unknown cause
(widespread inflammation)
Untx'ed= 20-25% develop cardiac sequelae (damage to coronary blood vessels and heart
muscle, scarring, cardiac calcification).
S/S=↑ ESR & C-reactive protein (shows inflammation), Fever (unresponsive to antibx, at least
5 days), red & dry conjunctivae, inflamed oral mucosa (dry cracked lips, strawberry
tongue), Edema (hands & feet, erythematous)
Cardiac= coronary aneurysm (leading to MI), inflammation, ECG changes, ↓LV fxn, mitral
regurgitation
TX= ↑dose IVIG w salicylate therapy, ASA
-Cardiac Catheritization= catheter inserted into peripheral blood vessel (angiography= w contrast)
Two kinds:
R sides venous= into RA
L sided arterial= into aorta & LV
Yields info on:
O2 sat in chambers of heart, pressure changes
CO or SV (amt of blood pumped out LV to aorta w each contraction
Anatomic abnormalities (obstruction)
RN Care:
Mark/check pedal pulses, Temp, v/s (q15), dressing (bleeding), fluids for hydration
Contraindication= diaper rash
Bleeding @ site= direct continuous pressure 2.5 cm above vessel puncture ←BLACK
BOX WARNING
-Fetal Circulation

BF (blood flow)= Oxygenated blood in thru placenta→ umbilical vein→ liver (some to portal/hepatic
circulation)→ inferior vena cava→ RA→ Foramen Oval (or pulm art out duct art)→ LA→LV→ aorta.
-Small amount goes to lungs (some of that blood diverted by ductus arteriosis)
-Post natal= clamping of cord ↑ systemic circulation, ↑ pressure closes foramen ovale. Duct art closes
about 4th day (fibrin deposits.... murmur heard until it closes)
-Cardiac Pressures
-RA= 70±5%, 3-7 mmhg. Not oxygenated, low pressure
-RV= 70±5%, 25/0 mmhg. Not oxygenated (no change from RA), ↑ in pressure since RV is a pump
-PA= 70±5%, 25/10 mmhg. Still not oxygenated, no big pressure change.
-LA= 97±3%, 5-10 mmhg. Oxygenated (blood has been to lungs), pressure ↑er than R side of heart
but lower than ventricle pressure
-LV= 97±3%, (O2 same, oxygenated) pressure 4x greater than RV
50-60 Preterm baby
65-80 Full term baby
100/10 Normal child
-Ao= 97±3%, 100/70. O2 same, pressure still high (sent out to perfuse body)

-Shunts/defects
Shunt= blood flow takes abnormal pathway (∆ in pressure in heart, blood takes path of least
resistance)
Cyanotic= (More Severe) Unoxygenated blood (hasn't been to lungs) gets out into system
circulation. ↓pulm flow
Acyanotic= oxygenated blood not getting out of heart/pulm into systemic circulation. ↑ pulm
flow (= enlargement)

-Ventricular Septal Defect (VSD) Acyanotic

-BF= RA→RV→pulm art→lungs→pulm vein→LA→LV
Abnormal opening in septum btwn LV & RV. ↑er pressure in LV so blood flows path of least
resistance into RV (instead of out aorta into systemic circulation). Size of hole varies (50%
of small ones close of own)
Causes ↑ pressure in pulm art (due to excess blood vol.) and RV( poss hypertrophy) and ↑O2
sat in RV
TX=Small hole left to close on own.
Large hole= Suture or patch (will collect firbrin/clots an eventually close)
Huge hole= PAB (Pulm Artery banding). ↓ amt of blood able to exit through pulm art
(since extra blood is being shunted there) Goal of tx is to ↓ amt of blood going to pulm
art. Surgery 3-4 yrs.
S/s= recurrent resp infections (warning sign!!!) fatigue, dyspnea, murmur, HF later in life if
unDX

-Atrial Septum Defect (ASD) Acyanotic

-BF= RA→RV→pulm art→ lungs→ pulm vein→ LA

Abnormal opening btwn LA & RV. ↑er pressure in LA so oxygenated blood follows path of least
resistance into RA.
Causes= ↑ pressure in R side of heart (due to excess blood volume) and ↑ O2 sat in RA (70)
due to mixing of blood.
S/S= growth retardation/small for age, fatigue, dyspnea, murmur, HF (later in life if unDX)
Tx=requires surgery for larger holes/ severe s/s ( holes will not close on own). Survival w
surgery (2-4 yrs) @99%

-Patent Ductus Arteriosis (PDA) Acyanotic

-BF= RA→RV→ pulm art→ lungs→ pulm vien→LA →LV →aorta
Ductus Art. reamins open. Pressure in aorta is 4x ↑ in aorta than pulm art so blood follows
path of least resistance back to pulm art (and to lungs).
LA & LV enlarged (due to excess blood going into pulm circulation and back to L side of heart).
Enlargement of L side
↑er O2 sat in pulm art (mixing of oxygenated blood thru patent duct art.)
Rubella linked!!!
Tx= Indomethacin (prostaglandin inhibitor that closes small % of them). If not, simple surgery
(3-6 yrs)

-Aortic Stenosis (AS) Acyanotic

-BF=RA→RV→pulm art→ lungs→ pulm vien→ LA→LV

Narrowing of aorta causes back up of blood. LV has to work harder to push blood through
narrowing. ↓ CO (=less perfusion) Neonate mortality 10-20%
S/S= faint pulses, hypotension, exercise intolerance
 TX= balloon dilation, then aortic valvectomy or replacement (open heart surgery). 25%
recurrence, poss aortic valve regurgitation.

-Coarctation of the Aorta (COA) Acyanotic

-BF= RA→RV→pulm art→ lungs→ pulm vien→ LA→LV→aorta

Narrowing anywhere along aorta. ↑es pressure proximal to narrowing. Blood backs up into L
side of heart (enlargement and ↑pressure). DIFFERENT BP IN ARMS/LEGS IS A BIG SIGN
←BLACK BOX WARNING
↑BP= above narrowing (brain, bounding carotid)
↓BP= below narrowing (lower body, weak/absent pedal or femoral pulses)
S/S= HA, epistaxis, poor lower circulation, mottling, DIFF BP IN LOWER AND UPPER EXT
TX= graft, angioplasty w balloon. Surgery 3-5 yrs.

-Tetraology of Fallot (TOF) Cyanotic

BF= RA→RV (↑er pressure in RV (due to pulm stenosis)→ VSD allows unoxygenated BF from RV to LV→
Aorta
-Most common cyanotic defect. Unoxygenated blood into circulation.
-Tetra means "4":
1. Pulm Stenosis of valve. Congenital
2. Aorta moved over towards septum (overwriting aorta). Congenital.
3. VSD (ventricular septal defect). Allows mixing of o2 and non-o2 blood. Congenital.
4. #1-3 leads to RV hypertrophy (enlargement due to excessive blood vol.)
S/S=paraoxymal dyspnea (diff breathing comes and goes), clubbing, squatting, growth retardation,
polycythemia (body tries to compensate for ↓blood o2.... leads to thickened blood= poss CVA),
murmur might not be picked up for 6 wks. Baby might have altered LOC.... leads MD to think
"cardiac workup"
Tx= close VSD, resect pulm artery

-Transposition of the Great Arteries Cyanotic

-BF=RA→RV→AORTA→LA→LV→PULM ART Not compatible with life!!!

Aorta & pulm artery switched!!!!
Unoxygenated blood into circulation.
Need ASD or VSD for life. will allow for some mixing of o2 and non-o2 blood.
S/S=cyanosis, dyspnea, polycythemia (thick blood= CVA), cardiomegaly
TX= (DX with US). no tx= 90% dead within 1 year
Rashkind= enlarge existing ASD
Blalock-Hanlen= make an ASD
Mustard Procedure=crisscross arteries by prosthetic means (? i think)

-Assessment for Congenital Heart Defects

RESP= recurrent resp infections, ↑RR, retractions, grunting
FEEDING= pulls back (needs air), fussy, falls asleep, never gets enough to eat/hungry
ACTIVITY=restless (sign of hypoxia), lethargic, doesn't attend to environment
COLOR=pale, color worsens in some positions
POSITIONING= ↓ muscle tone, flaccid, hyper extends neck (for more o2)
HR= ↑ (to circulate blood faster, greater perfusion)
CRY=weak, muffled

-PreOP/PostOP Care
Pre op
-Prevent: fatigue, infection
-adequate nutrition
-prepare family for surgery
-pt cannot have a current
infection
Post op
-monitor: resp fxn, cardiac fxn, F&E (don't
overload=CHF)
-Control metabolic rate (control fever.... ↑es
HR)
-Neruo: PERRL, grips, reflex, LOC (perfusion of
brain)
Comfort: morphine, Dilaudid, turn q 2 hrs

-CHF (congestive heart failure)

S/S= tachycardia, gallop, tachypnea, ↓urine output (=edema), ↓pulses, sweating, FTT (failure
to thrive), ↓exercise tolerance
Tx= ↓NRG use, feed in small amounts & often), maintain Temp, o2, diuretics, DIGOXIN
-Digoxin (Lanoxin) (anitarrythmic, inotropic)
Indication= HF, A-fib, A-flutter
Action= Slows the HR (ventricular rate), makes the heart work more efficiently . Increases
force of myocardial contraction.
Administration:
-in MICROgrams, no mg's. Be careful!!
-2 licensed RNs
-take apical pulse for 1 full minute
60=adult
70= kids
90-110= infant/toddler
Side effects=fatigue, bradycardia, n/v, arrythmias
BLACK BOX WARNING= Hypokalemia enhances Digoxin effects, ↑ing risk of digoxin toxicity.
Hyperkalmeia diminishes digoxins effect. Monitor Potassium levels
closely (3.5-5.5 mmol/L)
BLACK BOX WARNING= therapuetic serum digoxin range= 0.8-2 mcg/L. Observe for s/s
toxicity (bradycardia, n/v)
BLACK BOX WARNING= Infants rarely get more than 1ml (50mcg or 0.05mg) in one dose.
Have another RN check calculations.

-Rheumatic Fever
Inflammatory Disease. Affects collagen tissue (joints, heart, adb cavity)
S/S= child has untreated strep infection (up to 6 weeks prior). Can lead to rheumatic fever
↑ fever, sore nodules (on joints, reoccurring), adb pain (collagen tissue hold up
organs), erythema (rash on chest/abd), arthritis in joints (migrates around joints)
Cardiac= Valves= incompetent, regurgitating, pericarditis.
Chorea= pt has mood swings, coordination off
DX= ↑ESR and C-reactive protein (indicators of inflammation)
↑WBC (from prev strep infection)
↑ASO (measures strep antibodies)
Cardtitis=cardiac enlargement= seen in x-ray. Aschoff bodies= nodules on heart
(valves), Ekg= prolonged PR interval
TX=
Recurrence= PCN for life prophylactic ally or before procedures
Corticosteroids if inflammation in severe
Digoxin
Tx of ANY sore throat

RN care=
Bed rest w cardiac evolvement (change position, no PNA or bed sores)
Chorea= be patient, slow down for them
Take pulse for 60 seconds
Joint pain= be gentle moving them
Small meals

Complications of Diabetes Mellitus: Preexisting and

Gestational
-Production of insulin is absent or inadequate. Causes cell starvation (insulin is the "key" to getting
glucose into cells). P
-In absence of glucose, cells break↓ fats & proteins (leads to ketones in urine)
-glucose has hypersomotic pull (expands blood vol, blood vol that already increased in pregnant
woman). Causes cellular dehydration (hence being thirsty with hyperglycemia)
-In pregnancy, keep blood glucose <130 mg/dl (140 in other sources). Glucosuria results with elevated
blood glucose.
-Glucose readily crosses placenta, insulin does not
-3 "P's" of hyperglycemia= Polydipsia (excessive thirst), Polyphagia (excessive hunger), Polyuria
(excessive urination)
-↑ incidence w/ Latino, Native American, India subcontinent, Middle Eastern
-Breast feeding ↓ers insulin demand (thus at risk for hypoglycemia)
-No traveling recommended in 3rd trimester

-Pregnancy Adaptations with Diabetes

TRIMESTER NORMAL PREEXISTING GESTATIONAL
1st Less insulin needed Required Insulin dosage ↓ Required Insulin
(pregnancy hormones ↑ dosage ↓
insulin production)
2nd Insulin resistance due to Constantly monitor insulin @18-20 wks insulin
(begin↑) hormonal ∆'es ( dose increments (needs requirements > than
↓tolerance to glucose,↓ constantly ∆ing) pre-pregnant needs
hepatic stores) GDM shows up (2nd
trmstr)
3rd Able to meet insulin Double or quadruple Produce less insulin
(↑) demands insulin dose needed. Team than needed
management

-White's Scale
-Guide to classification of perinatal diabetes (method of classifying diabetes in pregnancy)
-alphabetical scale:
A-C= preexisting & gestational diabetes. Controlled w diet/exercise/insulin
D and above= produce IUGR babies (due to poor placental perfusion)

-Normal Metabolic Changes in Pregnancy

1st Trimester= ↑ in hormones (estrogen & progesterone) stimulate pancreas to make insulin.
↑ in tissue glucose stores happens & ↓ in hepatic glucose stores (can all cause
HYPOglycemia).
2nd and 3rd Trimester= Diabetogenic effect: in mom, hormones cause ↓ tolerance to glucose,
↑ resistance to insulin and ↑ hepatic glucose production (all ensures abundant glucose supply
for fetus). HPL (human placental Lactogen) & other hormones ↑ tissue resistance to
insulin. In short, Diab. effect = ↓insulin sensitivity.
Birth= expulsion of placenta (3rd stage of pregnancy) causes abrupt ↓ of hormones. Mom
quickly regains prepregnancy insulin sensitivity (7-10 days w/o breast feeding)

-Fetal Effects From Diabetes & Pregnancy

Goal= euglycemia w/o vasular disease (placental compromise)
Maternal Hyperglycemia-fetal hyperinsulinemia (producing lrg amts of insulin to deal with lrg
amts of glucose crossing placenta from mom)
Macrosomia= insulin acts as a growth hormone. Baby is large w/ immature organs that have
fat deposits. Monitor LS ratio, want 3.5:1 instead of 2:1 b/c lungs are immature. Risk for
injury/trauma at birth due to size.
IUGR= if there is ↓ placental perfusion.
Neural Tube defects= ↑ incidence if blood glucose not controlled at time of conception
(MSAFP)

-Gestation Diabetes Mellitus

DX= usually in 2nd half of pregnancy, 18-20 weeks (due to 1st trimester ↓ in insulin demand...
it masks it). Some manage with diet/exercise, others require insulin.
Index Pregnancy= 1st pregnancy where they DX gestation diabetes.
Management= Screen all women early (initial and 24 wk visit)
Goal= euglycemia & delivery when fetal lungs are mature and before complications.
Utilize interdisciplinary team
Tests= 50g oral glucose test (1 hr glucose challenge or glucose tolerance test [GTT]).
+>130-140
100g 3 hr GTT +>130-140
HbA1c= Hemoglobin A1c is the portion of hemoglobin that binds with glucose (or
becomes "glycosylated). A % of them become saturated for the life of the RBC.
This test is a measure of glycemic control over time (previous 4-6 weeks)

-Assessment in Clinical Practice for Diabetes

NORMAL PREEXISTING GDM
 -HX & urine dipstick (looking
for glucose and ketones) @
office visits
Routine 50g 1hr GTT @ 24
wks
Possible reference for 100g
3hr GTT (if 1hr GTT is +)
-Whites Scale to ID vascular
disease
-Urine dipstick (glucose &
ketones) @ office visits
Assess diet, exercise, insulin
(no 1hr GTT since we know
she has DM)
HbA1c, diet, exercise, insulin
regulation (frequent ∆es in
insulin need w pregnancy)
-Asses risk factors (family HX
& maternal HX)
-Urine dipstick (glucose &
ketones) @ office visits
50 g 1hr GTT is s/s before 24
weeks
HbA1c & plan to reevaluate at
6wk Post Partum visit (to see
if Mom returned to
prepregnancy norms

-Target Blood Glucose Levels in Pregnancy

Fasting Blood Glucose (FBG)= 60-105 mg/dL ac (before meals). Same for GDM
1hr Post Prandial (after meal)= <155 mg/dL
2hr PP=<130 mg/dL
Bedtime= 90-120 mg/dL
2-4 am lull= 60-120 mg/dL (everyone experiences a dip in BS btwn 2 and 4 am)

-Daily Management in Pregnancy

Goal= euglycemia, normal weight gain
Diet= 3 meals, 3 snacks
Meal= 40-50% carbs, 15-20% protein, 20-30% fat
Snack for bedtime= protein and carbs to fight 2-4 am blood glucose lull
Exercise= daily, 1hr after meals (15-30 mins walking)
Blood Glucose Monitoring= 4x daily or more:
FBS (fasting blood sugar) HS (before bedtime)
AC (before meals) 0200 (2-4 am lull)
1 or 2 hr pp (post prandial or before meal) HbA1c

-Insulin Administration During Pregnancy

Use Human insulin= rxn less likely
Pump insulin use okay
No premixed (pregnant womans insulin needs ∆ too rapidly for this) (Long acting might cause
hypoglycemia at night)
4 dose approach (AC x3 meals, HS)
Oral hypoglycemics= Glyburide, Metformin, Glucophage okay. All others are teratogenic.

BRAND/NAME ONSET PEAK DURATION COLOR

Regular (Humulin R, 0.5-1 hr 2-3 hr 3-6 hr Clear
Novolin R)
NPH (Humulin N, Novolin 2-4 hr 4-10 hr 10-16 hr Cloudy
N)

-Fetal Assessment with Diabetes (begins early and often)

US = 18 & 24 wks
Biophysical profile= 28 & 32 wks (by ultra sound, looking for macrosomia, IUGR...)
MSAFP= 16 -18 wks (Maternal Serum Alpha Fetal Protein. Shows neural tube defects, value
will be ↓)
AFI=Amniotic Fluid Index= looking for polyhydramnios (amniotic fluid contains fetal urine...
excessive urination is a s/s of hyperglycemia). Assess LS ratio... can we deliver now?
Kick Counts=(fetal movement) @ 25 wks (done daily by mom at home)
Fetal Echocardiogram= 20-22 wks and repeated at 34 wks. Looking for cardiac anomalies
(VSD, ASD etc).
Doppler Blood Flow Studies= asses vascular issues (placental compromise... leads to IUGR)

-Post Partum Management

NORMAL PREEXISTING GDM
 Greatly reduced insulin needs
Metabolism normal in 3 wks
(back to prepregnant state)
Significantly reduced insulin
needs
Need for insulin may be
delayed 24-72 hrs after
delivery
Monitor glucose levels QID or
PRN
Meal/exercise plan for
lactation
35-55% have s/s DM in 5-15
yrs
Review= diet/exercise,
normal weight, s/s hyper-
hypoglycemia
Avoid oral contraception
(chemically ∆es body) Use
barrier method
FBS 1 day pp (reevaluate @
6wks)

Pediatric Genitourinary Dysfunction

Black Box Warning
-No fleets enema for Renal Failure= hyperphosphatemia
-Automatic UTI eval= incontinence in a toilet rained child, strong smelling urine, frequency/urgency

-Wilm's Tumor
Most common renal tumor. Prognosis: stage 1&2= 90%; Mets= 50%
Embryonal adenocarcoma= pt is born with it. Dx'ed in infancy or toddlerhood
Usually unilateral (favors LEFT kidney)
Once confirmed, do not palpate. Might break tumor apart ("seed" abd cavity with tumor cells)
S/S= firm smooth palapable mass (often found by parents), HTN (kidneys not working properly
to filter), vomiting, abd pain, fever, hematuria, CA s/s= pallor, weight loss, lethargy
DX Eval= family hX (cancer in general, congenital anomalies)
urinalysis =Hematuria
24 hr= is it Wilms tumor or neuroblastoma? ↑ catecholamines = neuroblastoma
X-ray/scans= look for mets
IVP= intravenous pilogram= contrast to see
TX= surgical removal with in 24 hrs (tumor is aggressive, mets quickly) Remove tumor and
affected tissue (lymph nodes)
Stage 1= confined to ONE kidney, resected. No mets.
Stage 2= mets beyond kidney but all can be removed
Stage 3= mets confined to abdominal cavity, cannot remove all
Stage 4= mets elsewhere in body (lungs, liver, bone, brain)
Stage 5= bilateral kidney involvement (transplant necessary)
Radiation= not <18 mo's age in Stage 1
Chemo= vincristine (n/v, hair loss, constipation[give colace])
RN= Palpate to find tumor, then hands off. Prevent rupture. Pre & Post op teaching
Post op= v/s, BP, I&O (intra-abdominal hemorrhage), inspiromter (prevent PNA),
intestinal obstruction (due to handling during surgery), adjunct thereapy (chemo,
radiation on 2nd or 3rd day)

Hypospadias
Urethral opens below meatus (urethra folds fail to close) (epospadias= ABOVE meatus,
less common)
Can be accompanied by= undescended testicles, inguinal hernia, Chordee (fibrous band cut in
surgery, curves penis)
Family HX (don't circumsize, might need tissue when surgically fixing)
TX= Goal= normalize appearance/fxn
Create opening in correct place. Fix Chordee
6-18 mo's (before child realizes they are "not normal")
 Post op= Large pressure bandage (sedation or restraints?), suprapubic catheter until penis
heals
Complications= fistula, infection, hematuria, frequency, dysuria

Exstrophy of the Bladder

Born with bladder outside of body (picked up in US, born c-section). Bladder seen as red
seeping (urine) mass
Can effect joints (hip socket rotated posterolaterally)
Female= labia separated, opening tilted
Male=inguinal hernia, undescended testicles, epospadias
TX= Goal= prevent or tx infection, avoid trauma, promote growth and development. Promote
bonding (NICU)
Surgery= with in 48 hrs. Keep sterile and moist. Monitor fro fluid loss.
1) Put baldder inside of abd cavity
2)fix epospaidias
3)fix other complications (reconstructions of ureters)
Complications= infection, hydronephrosis (urine backflow into kidneys, heptomegaly)
Reflux= antibx, antispasmodics, analgesics, sedative
Psychosocial= inadequate penis size, different looking gentialia, ? procreation, female rejection

Cryptorchidism
Undescended testicles. Absence of 1 or both
More prevalent in premies (descend later in life). Full term= 3-4%, Preterm= 17%
Palpable vs impalpable= US if cannot be found by palpation.
Un tx'ed= infertility, ↑ risk for testicular cancer, tumors, hernia, testicular torsion (blood
vessels get wrapped around, cut off ... surgical emergency)
Tx= Serum testosterone/hormone therapy
Orchidopexy= correct by age 2, simple surgery
Teaching= testicular exams later in life

UTI
Common in male up to 4 mo's, females (short urethra...3/4 inch, 1½ inche in adulthood)
Don't= use bubblebath, tight nylon panties,
Do= wipe front to back, pee before/after sexual intercourse, adequate urine output, frequent
bladder emptying
Untx'ed= septicimiea and death
Repeated infections:
Damage to bladder walls/ valves (vesicouretoral),
Scarring/loss of renal tissue
Pyelonephritis= reflux of urine to kidneys (due to dilated ureters) causing
infection/inflammation
S/S=
Infant= fever, vomiting, diarrhea, irritability, lethargy, poor feeding, poor weight gain
Child= dysuria, urgency, fever, adb pain, enuresis
DX= Us (anatomical problem?)
Cystourethrogram= see the system in action, shows reflux
Goal of TX= cure existing infection, identify/correct predisposing factors, prevent recurrence

Acute, Uncomplicated UTI (dx)

UTI of an older child (schoolmate) 80% E. Coli
S/S=urgency, frequency, uncomfortable, pain
TX= Trimethoprin (Septra), Amoxicillin (broad spectrum synthetic PCN), OR IM
Amikacin (1 time dose)
Recurrent UTI
Infection that occurs after previous one has been successfully tx'ed (urinalysis was
clean)
TX= place on prophylactic antibx (low dose) for years until child grows out of it

Complicated Infections
Child= <3 yrs, Male, Febrile. E. Coli, Proteus, Klebsialla Pseudomonas
TX= IV meds for at least 48 hrs (with 2 antibx)
 Collecting Urine Specimens
Potty trained= midstream clean catch (like with adult)
Baby= bag around meatus, check frequently
Straight cath= possibility of contamination
Suprapubic Aspiration= ABSOLUTE STERILE specimen needed. Needle into abd cavity
into bladder.
Painful, topical anesthetic only. Done by MD

Vesicoureteral Reflux
Abnormal backflow of urine from bladder, up ureters (and possibly into kidneys... High grade
VUR[pyelonephritis])
29-50% following UTI
Can be from noncompliance or intolerance to antibx
Primary Reflux= Part of submucosal ureter is congenitally short ( part that tunnels into
bladder)
Secondary Reflux= ureter/valves damaged by chronic infection
Tx= Surgical Intervention= fix anatomic abnormality
Lengthen submucosal segment, move site where ureter tunnels into bladder
Post-op=3 tubes:
2 stents, 1 for each ureter. First 48-72 hrs urine will drain from here
1 stent from bladder. After inflammation goes does, urine will drain from here
Color= bright red (hematuria) then orange (pee and blood), then clear yellow
Antibx (stents offer bacteria access to sterile warm environment)
Pain relife & antispasmodics (just touching bag can cause spasm/pain in ureters)

Acute Poststreptoccocal Glomerulonephritis (AGN)

Inflammation of the glomeruli of the kidney
Strep= if untx'ed will lead to 2 things= this and Rhuematic Fever
Strep Antibodies make anit body/antigen complex (made of proteins) that damage
kidney
S/S= ↓GFR, edema, hematuria & proteinuria (shouldn't be allowed past kidney) Pale due to
lost rbc's
= puffy face, ↓ grade fever, dark amber urine, HTN (only w nephritis) 140's. 150's
DX=
Hematuria and protienuria (kidney not filtering properly)
↑BUN (evals kidney fxn, low= failure) and Creatinine (excreted by kidney, used as a
marker of kidney fxn)
↑ASO (measure for strep infection), ↑ESR (shows inflammation)
Throat Culture
RN Care
Fluid restriction (edema)
Diet restriction to carbs and fat (NA and K might be restricted)
Antihypertensives, diuretics, antibx,
Diuresis in 1-3 weeks
D/C when:
Normal weight and BP
Black Box Warning
Suspect AGN with s/s of: Periorbital edema (parents reprot in am)
Loss of appetite, ↓ urinary output, tea colored urine, preceded by strep

Nephrotic Syndrome
Alteration in renal fxn sue to glomerular injury. 90% idiopathic. Boys 2:1
Defect in glom membrane allowing protein to leak out→ lowers colloid osmotic pressure→ fluid
leaves vascular space for tissue→ edema
S/S= swollen eyes and abd (ascites),
DX=
Urinalysis (4+ protienurea), ↓ Albumin (it's a protein.... lost in urine)
Creatinine Clearance (excreted by kidney, used as a marker of kidney fxn)
Serum Cholesterol ↑
Na↓(due to water)
 ↑Hgb, Hct, Platelets, Specific Gravity (urine concentrated, full on protein)

TX=
Bedrest with significant edema
Steriods 3-4 x daily (prednisone with food)
Diuresis on own in 6-14 days
Cytoxin= used if steroids don't work. Chemo drug... will suppress bone marrow.
RN
Minimal urine output of child= 1ml/kg/hr
Diuretics, daily weight (marker of fluid status)
Prevent infection (steroids mask s/s of infection)

(AGN) NEPHRITIS NEPHROSIS

+ strep No strep
+ HTN No BP ∆
Pronounced Hematuria (some Pronounced Proteinuria (4+)
Proteinuria)
Happens at younger age; Boys

Nephrosis Evaluation
Normal urine SG (was concentrated due to albumin [protein] loss); clear and yellow in color
Normal Electrolytes
Normal Weight (diuresis of edema)
Balanced I&O
Lack of proteinuria