N427: Test 6

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N427: Test 6 by Mind Map: N427: Test 6

1. Endocrine

1.1. Anatomy & Physiology

1.1.1. Hormones Local General

1.1.2. Secretion -tropic hormones Negative feedback loop "Master gland" = ant. pituitary Releasing or inhibitory hormones

1.1.3. Purposes Growth Sexual development

1.2. Pituitary Disorders

1.2.1. GH deficiency R/T decreased pituitary activity Infarction Infection Trauma Tumors Psychosocial dwarfism Insufficient GH Manifestations Slow growth (>3% on growth charts) Hypoglycemic seizures Hyponatremia Delayed dentition Youthful facial features Delayed skeletal maturation Diagnostics Low, insulin-like growth factor X-rays determine bone age Provocative GH testing Nursing care Monitor growth Education HRT Nutrition Finances

1.2.2. GH excess Oversecretion of GH in kids Epiphysial plate still open r/t hypogonadism Excessive linear growth Heights may reach up to 8 feet Usually caused by pituitary adenoma Manifestations Increased IGF Increased muscle, viscera development Increased in wt in proportion to ht HA r/t IICP with tumor Treatment Early detection Surgery Radiation therapy Nursing care Growth patterns Education Counseling re: appearance

1.2.3. DI Undersecretion of ADH Uncontrolled diuresis Most common post. pit. disorder Usually caused by brain tumors & treatment Inability to concentrate urine Manifestations Polyuria, polydipsia Dehydration Weight loss hTN Hypernatremia Low urine specific gravity Diagnostics Serum electrolytes Urinalysis Fluid deprivation test Management Assessment HRT Education Fluid replacement Electrolyte monitoring Dehydration treatment Low sodium diet Don't restrict fluids!

1.2.4. SIADH Excess ADH CNS infection Trauma Tumors Some pulmonary dx Manifestations Increased urine specific gravity Decreased serum osmolality Water intoxication HTN Crackles Seizures Weight gain Treatment Fluid restriction Diuretics Demeclocyline Hypertonic saline IVF

1.2.5. Precocious puberty Early manifestations of sexual development Girls <8 Boys <9 Premature activation of HPG axis Secondary sex characteristics develop >> Activated by release GnRH Causes Central Peripheral Treatment Synthetic GnRH Monitor adult height Psych support

1.3. Thyroid Disorders

1.3.1. Hypothyroidism Etiology Born w/o ability to make TH R/T thyroid dysgenesis Present at birth, but delayed diagnosis Common with Down syndrome Transient or permanent May progress to mental retardation Manifestations Not obvious in newborns Around 6 wo Thick, dry, cool skin Coarse, dry hair Bradycardia, hTN, hypothermic Protruding tongue Hypotonia Diagnosis Mandatory heel-stick Risk for permanent mental delay if untreated Treatment Lifelong HRT Levothyroxine sodium Nursing care Good screening, monitoring Education Meds don't correct mental defects

1.3.2. Hyperthyroidism Rare in kids Usually caused by Graves disease Autoimmune response to TSH receptors >> increased TH Manifestations Various Exophthalamos Diagnostics High T4, T3 Decreased TSH Management Anti-thyroid drugs* Thyroidectomy (complications) Ablation w/radiodine Nursing care Alert for S/S Quiet environment Education Surgical care Thyrotoxicosis

1.4. Adrenal Disorders

1.4.1. Cushing syndrome Excess free cortisol Adrenal tumor Prolonged steroids Manifestations Hyperglycemic HTN Hypokalemia Susceptible to infection Diagnostics FBG Electrolytes 24-hr urine Radiographic studies Dexamethasone suppression test Therapy Surgery for tumor Lifelong cortisol replacement Nursing care Alter steroid treatment Post-op teaching for CRT No abrupt DC of meds

1.4.2. Congenital adrenal hyperplasia Etiology Decreased enzyme activity Excess androgen production Manifestations FTT Weakness Vomiting Dehydration Salt-losing crisis Short stature Premature 2ndary sex characteristics Elevated K, decreased Na >> cardiac arrest Diagnostics Initial inability to assign sex Chromosome typing Pelvic ultrasound Increased 17-OHP levels* Electrolytes Management Decrease androgens & replace hormones Affirm sex; reconstructive surgery Glucocorticoid RT Nursing care Psychological effects Parenting styles Home health Genetic counseling

1.4.3. Chronic adrenocortical insufficiency Addison disease Decreased adrenal hormones R/T destruction of gland or neoplasms May be idiopathic Manifestations Hypoglycemic, hyponatremic Dehydration Hyperpigmentation Diagnostics Functional cortisol reserve ACTH-stim test Decreased serum cortisol Treatment Hydrocortisone Aldosterone replacement (severe) Nursing care Drug therapy education Follow-up care Stress-free environment

1.4.4. Pheochromocytoma Benign tumor Adrenal gland or anywhere w/chromaffin cells Secretes catecholamine Manifestation HTN Tachy HA Diaphoresis Diagnosis 24-hr urine for catecholamine CT or MRI Treatment Uni- or bilateral adrenalectomy Removal of tumor Premedication Surgical crisis Nursing care Post-op Repeat 24-hr urine Monitor for decreased bp, glucose Lifelong HRT if both adrenal glands removed

1.5. Pancreatic Disorders

1.5.1. Diabetes mellitus Type 1 Idiopathic or autoimmune Usually in kids or slim young adults May be triggered by virus Most common endocrine dx for children Type 2 Insulin-resistent or decreased production Increasing incidence in pediatrics Diagnostics FSG RSG OGTT Manifestations Frequent infections (esp. yeast) Slow healing 3 P's Treatment Type 1 Type 2 Acute complications Hypoglycemia DKA

1.6. Phenylketonuria

1.6.1. Overview Autosomal recessive Absence of phenylalanine hydroxylase Cannot metabolize phenylalanine High levels in blood, urine Decreased melanin production

1.6.2. Manifestations Musty urine Growth retardation Frequent vomiting Irritability & hyperactivity Hyperactivity, hypertonia, hyperactive deep tendon reflexes Eczema-like rashes Later effects Mental retardation Seizures Death

1.6.3. Diagnosis Want to prevent intellectual disability Progresses within few weeks of life Takes a long time for onset Mandatory heel-stick at birth Mandatory by law in all 50 states Feed newborn before specimen collection Screen no sooner than 48 hrs after birth If positive, repeat test; then, refer for treatment Guthrie test with phenylalanine >4

1.6.4. Management Early treatment = improved prognosis Diet with no high protein foods Very limited selection Need lots of education Nutritional consult High diet costs Especially important for females Special infant formulas Goal is to maintain levels 2-6 mg/dL in infants 2-10 mg/dL in kids +12

1.6.5. Nursing care Early detection** Extensive diet education Manage diet for life Nutritional consult Genetic counseling

2. Renal

2.1. Pediatric Differences

2.1.1. Most growth in first 5 yrs

2.1.2. Less efficient regulation Acid-base Electrolytes Drug elimination

2.1.3. Smaller bladder 20-50 mL at birth Little return on cath Add to child's age in oz

2.1.4. Urine output 2 ml/kg/hr (infants) 0.5-1 ml/kg/hr (children) 40-80 ml/hr (teens) 1-2 ml/kg/hr (children)

2.1.5. Fluid requirements 1-10 kg: 100 ml/kg 11-20 kg: 1000 + 50 mL/kg 20+ kg: 1500 mL + 20 ml/kg

2.2. Urinalysis

2.2.1. Pale yellow color Red Dark Orange (AZO)

2.2.2. Clear turbidity

2.2.3. 1.010-1.030 SG Higher if dehydrated

2.2.4. Negative or rare components RBC WBC

2.2.5. Few epithelial cells

2.2.6. pH of 4.5 - 8 Elevated: UTI, stones, bacteria

2.2.7. Low creatinine r/t low muscle mass

2.3. External Genital Abnormalities

2.3.1. Bladder exstrophy Eversion, protrusion Males > females Diagnostics Appearance Ultrasound Nursing care Sterile plastic wrap for 48-72 hrs Skin assessment with protectant Immobilize pelvis UO 2-person diaper change

2.3.2. Hypospadias, epispadias Abnormal location of urinary meatus Circumcision Hard to if uncircumcised Cannot have procedure Foreskin used to repair defect

2.3.3. Phimosis Cannot retract foreskin Be careful during cleaning Can be fully retracted by age 2-3

2.3.4. Cryptorchidism Undescended testicle(s) Spontaneous remission @ 3months If not, surgery @ 12 months Infertility/malignancy

2.3.5. Hydrocele Fluid-fill scrotal mass Communicating (resolving) Non-communicating Spontaneous resolution @ 1 year Transillumination

2.3.6. Testicular torsion Spermatic cord twists, cuts of blood flow Manifestations Usually when asleep No cremasteric reflex Severe pain N/V Scrotal swelling

2.4. Lower Urinary Tract Disorders

2.4.1. Patent urachus Should close during development Umbilical cord Bladder Suspect when UC fails to drop off After 1-2 weeks Surgical repair

2.4.2. Obstructive uropathy Impedes urine flow >> backflow to kidneys Hydronephrosis Renal scarring Suspect if pediatric UTI Renal ultrasound Hydronephrosis

2.4.3. Vesicoureteral reflux Backflow from bladder into ureter Incomplete emptying Stagnant, infected urine Spread of bacteria to kidney Diagnostics Renal ultrasound VCUG Treatment Surgery Prophylactic ABX

2.4.4. Cystitis Lower UTI Females > males Over age 3 months Increased risk if not circumcised Causes E. coli Hygiene Constipation Sexual activity Urinary stasis Manifestations Fever FTT V/D Urinary odor GU symptoms Diagnostics UA/UCX Renal ultrasound or VCUG Treatment Antibiotics Antipyretics Prophylaxis

2.5. Upper UT Disorders

2.5.1. Pyelonephritis Manifestations Very high fever Chills CVA tenderness Very ill True kidney infection PO & IV antibiotics IV first 3 days Then two wks of PO

2.5.2. Acute glomerulonephritis Secondary to strep Nephrogenic strain Toxin damages kidney Manifestations Abrupt onset of pain Hematuria, proteinuria, azotemia HTN Tea-colored urine Edema Eelvated BUN, C, WBC, ESR Positive ASO titer Anti-Dnase B Anemia Treatment BEDREST Na, K restriction Diuretics Anti-HTN ABX High recovery rate Education

2.5.3. Hemolytic uremic syndrome R/T E. coli Uncooked meat Not regular E. coli Damage to glomerulus More common in summer Most CC of ARF in kids Triad Hemolytic anemia Thrombocytopenia Renal insufficiency Manifestations Severe GE HTN Pallor Oliguria V/D/A/P Jaundice, edema Urine alterations Metabolic acidosis Dietary care Fluid restriction High cal, carb diet Low protein, Na, K, P Meds Kayexalate Anti-HTN Calcium gluconate Plasma, then blood Dialysis*

2.5.4. Nephrotic syndrome Massive proteinuria Hypoalbuminemia Hypoproteinemia Hyperlipidemia Altered immunity Never have hematuria Manifestations Gradual edema Pallor HTN Anorexia Malaise Frothy urine Pale, shiny skin Prominent veins Brittle hair Treatment Steroids Albumin + lasix Limit salt, protein in diet

2.5.5. Renal failure Acute May be reversible Onset of days to weeks Types Manifestations Treatment Chronic Progressive, irreversible Manifestations Treatment

2.6. Renal Transplantation

2.6.1. Immunosuppressants

2.6.2. HLA typing & match

2.7. Enuresis

2.7.1. Involuntary voiding that is abnormal Age 5-6 years Primary (control) or secondary (stressed)

2.7.2. Lack of vasopressin (ADH)

2.7.3. Meds: DDAVP, oxybutynin

3. Fluids & Electrolytes

3.1. Overview

3.1.1. Fluid distribution 2/3 IC 1/3 EC

3.1.2. pH 7.35-7.45 Homeostasis Natural acids Carbonic (lung) Metabolic (kidneys)

3.1.3. Fluid distribution Infant Baby

3.2. ECFVD

3.2.1. Hypovolemia or dehydration

3.2.2. Not enough fluid in EC space

3.2.3. Three types Isotonic Most common Equal loss of Na, water Hypertonic Water loss > salt Causes Hypotonic Loss of Na > water Severe or prolonged V/D Burns or renal disease Treated with IVF w/o electrolytes

3.2.4. Nursing care % weight loss LOC Treatment Oral IVFs Monitoring Electrolytes Urine appearance, SG I&O UAP + RN INTERPRET IT Emergency Address cause Neglect Improper formula

3.3. ECFVE

3.3.1. General Saline retention r/t aldosterone Dependent edema Causes Disease processes Glucocorticoids Excess IVFs Nursing care I&O IVF administration

3.4. IFVE

3.4.1. Edema Increased BHP Decreased BOP Increased IFOP Blocked lymphatics

3.4.2. Treat cause

3.4.3. Nursing care Daily wts, measures I&O Skin care Body image Pain Fluid restriction care Meds Albumin + Lasix Never Lasix alone

3.5. Sodium

3.5.1. Hyper >145-156 "Shrinking" Na > Water Thirst DUO Treat w/hypotonic IVF Isotonic, then hypotonic Dehydration, then salt imbalance Nursing care Infant feeding Weight checks Water deprivation abuse Water flushes for ages +6mo

3.5.2. Hypo 131-132 "Fat" Nursing care IVF Anticipatory guidance Safety

3.6. Potassium

3.6.1. Normal range: 3.3-5.5

3.6.2. Hyper Causes PO intake Renal failure Older blood transfusions Crush injuries SCD Chemo Renal insufficiency r/t excretion**** Muscle dysfunction Ascending weakness Hyperactive gut Cardiac: tachy, arrythmias, arrest! Treatment Limit intake Excretion Drive it back into cells Nursing care UO before any IVF Safety Diet restriction MOST LETHAL!

3.6.3. Hypo Muscle dysfunction Underactive gut Weakness Problems w/RR Arrhythmias Replacement therapy Tastes awful Mix with juice* Nursing care ASSESS Safety K supplement education IV infusion care Etiology NPO, intake problem Hyperinsulinemia Alkalosis Hyperalimentation V/D or NGS High aldosterone Albuterol continuous

3.7. Calcium

3.7.1. 8.4-10.6 range

3.7.2. Hyper Etiology Antacids Hyperparathyroidism Bedrest HCTZ Manifestations Decreased DTR FTT N/V/C Cardiac arrest Treatment Push fluids Lasix Glucocorticoids Calcitonin Phosphate (inverse relationship) Acidify urine r/t stone formation Safety re: weakness

3.7.3. Hypo Etiology Poor diet Eating disorders Uremic syndrome Blood transfusions Liver dysfunction Burns Wound drainage Steatorrhea Manifestations Tetany Spontaneous frxs Low Mg* Treatment Replacement Vitamin D Diet Nursing care C or T signs Diet ed No IM calcium

3.8. Magnesium

3.8.1. Hyper Etiology increased intake Mag sulfate for labor Laxatives or enemas Altered renal function Manifestations Decreased muscle irritability hTN or bradycardia Absent DTR Treatment Prevention Excretion

3.8.2. Hypo Manifestations Tetany Hyperactive DTRs Cardiac arrest Seizures Treatment IV Mg Etiology NPO Long term IVF Malnutrition Severe diarrhea Large transfusions Loss via diuretics, DKA, NGS

3.8.3. Nursing care Diet Emergency equipment during admin DTRs

3.8.4. 1.5 - 2.7