1. Chapter 15: Fluid Imbalance
Dehydration: Infants
Subject to greater evaporation of water from skin
Rapid respirations increase fluid loss
When diarrhea is present, additional fluid is lost
Immature infant kidneys = poor water conservation
Dehydration occurs more quickly in infants than in adults.
What is the difference between maintenance therapy and deficit therapy?
The electrolyte content of oral fluids is particularly significant in the care of infants and small children with disorders of fluid balance and those receiving infusions.
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2. Fluid Imbalance
Classification of dehydration is based on serum sodium levels
Isotonic
Hypotonic
Hypertonic
Maintenance therapy vs. deficit therapy
Adjusted continually for patient’s condition
Oral fluids
Parenteral fluids
Given by route other than digestive tract
Why are the classifications of dehydration important?
Oral fluids are preferred if possible.
Requires patience from a busy nurse, take the time to offer fluids to toddlers and infants.
Accurate record of intake and output must be maintained.
Allows the physician to determine whether IV fluids are necessary.
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3. Fluid Imbalance Overhydration
Body receives more fluid than it can excrete
Can occur in patients with normal kidneys who receive intravenous fluids too rapidly
Can also occur in a patient receiving acceptable rates of fluid, especially when the patient’s illness is related to disorders of fluid movement
Edema: presence of excess fluid in the interstitial spaces
Edema in infants may first be seen about the eyes and in the presacral, occipital, or genital areas
How does the nurse assess for pitting edema?
Taking accurate daily weights is indispensable, as is close attention to body-weight changes.
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4. Urinary Tract Infection
Description
Bacterial invasion of the upper urinary tract (kidney and ureters) or lower urinary tract (bladder and urethra)
Vesicoureteral reflux
Primary contributing factor to upper UTIs
Rated I-V
Malfunctioning valve at the junction of the ureter and bladder lets urine reflux up the ureters toward the kidney
Bacteria from urine can cause pyelonephritis and renal damage
Diagnosed via ultrasound and voiding cystourethrogram
Why are urinary tract infections more common in girls?
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5. Urinary Tract Infection
Signs and symptoms
Poor feeding, fussiness, delayed growth, foul-smelling urine, and incontinence (in a child who has been previously trained)
Many adolescent girls exhibit classic signs of UTI (frequency, urgency, pain on urination, blood in the urine) after the first episode of sexual intercourse
High fever, chills, flank pain, and abdominal pain can indicate kidney infection (pyelonephritis)
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6. Urinary Tract Infection
Treatment and nursing care
7- to 14-day course of an appropriate antibiotic, generally sulfamethoxazole-trimethoprim (Bactrim, Septra)
Penicillins and cephalosporins may also be ordered
Nurses need to teach proper hygiene
No bubble baths or irritating diaper wipes
Wiping from front to back
Other preventive measures include wearing cotton underwear, adequate fluid intake, encouraging children to not put off going to the bathroom when the urge is felt, investigating and treating signs of intestinal parasites (pinworms)
How can the urine be acidified?
Sexually active girls should urinate after sexual intercourse.
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7. Acute (Post-streptococcal) Glomerulonephritis
Description
Occurs as an immune reaction caused by a Group A beta-hemolytic streptococci
Signs and symptoms
Urine is smoky brown in color or bloody
Periorbital edema in the morning; edema spreads to the abdomen and extremities due to gravity
The child may have fatigue, headache, abdominal discomfort, and vomiting
Oliguria: Decreased urine output, often caused by sodium/fluid retention
Anuria: body’s suppression of urine formation; may necessitate dialysis
How long after a streptococcal infection does acute glomerulonephritis usually occur?
Protein, RBCs, WBCs, and casts may be found upon examination of the urine.
Complications such as renal and cardiac failure and encephalopathy may also occur.
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8. Acute (Poststreptococcal) Glomerulonephritis
Treatment and nursing care
Prevent the child from becoming overtired, chilled, or exposed to infection
A low-sodium diet may be ordered
Furosemide (Lasix) if significant edema and fluid overload are present and renal failure is not severe
Penicillin is given if the streptococcal infection persists, but it usually does not alter the course of the disease
Persistent anuria may necessitate dialysis
Why would fluid restrictions be ordered?
The nurse should try to make the period of bed rest as pleasant as possible by providing quiet diversions.
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9. Nephrotic Syndrome (Nephrosis)
Refers to a number of different types of kidney conditions that are distinguished by the presence of marked amounts of protein in the urine
Signs and symptoms
The characteristic symptom of nephrosis is edema
The edema shifts with the position of the child during sleep
The urine appears dark and frothy
Urine output can be decreased
Vomiting and diarrhea may also be present
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10. Nephrotic Syndrome (Nephrosis)
Treatment and nursing care
Control of edema—steroids, diuretics, and albumin
Diet—well-balanced; high protein; salt restricted
Fluid balance—the patient’s urine must be carefully measured; weight pt daily
Care of the skin—good skin care is especially important during periods of marked edema
How long does prednisone therapy continue?
The child is weighed daily to determine changes in the degree of edema.
Because of the amount of edema in the lower extremities and fluid stasis, cellulitis can occur.
Serve small quantities of food, attractively arranged on brightly colored dishes.
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11. Nephrotic Syndrome (Nephrosis)
Treatment and nursing care (continued)
Positioning— repositioned frequently to prevent respiratory infection and skin breakdown
Infection prevention—assessment for and protection from infection is critical
Emotional support—parental guidance, education and support should be given by all members of the nursing team
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12. Enuresis Bed-wetting Child should never be punished
Primary: child has never been dry for an extended period of time
Secondary: bed-wetting after the child has been dry
Family history
Child should never be punished
Time is usually all that is needed; out grow it
Therapy includes medications, fluid restriction after evening meal, waking a child to void, bladder training, bed pad alarms upon initiation of voiding
According to Hockenberry & Wilson (2009), the inappropriate voiding of urine occurs at least twice a week for at least 3 months, and the age of the child (chronologically or developmentally) is at least 5 years.
Bedwetting is typically outgrown by 8 years old.
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13. Hydrocele
An excessive amount of fluid in the sac that surrounds the testicle; causes the scrotum to swell
Common in the neonate, and in many cases, the condition corrects itself as the baby grows
If a chronic hydrocele persists in the older child, it is corrected with surgery
Routine postoperative nursing care is given
Same-day or outpatient surgery may be arranged
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14. Undescended Testes (Cryptorchidism)
Description
One or both testes fail to descend into the scrotum
Because the testes are warmer in the abdomen than in the scrotum, the sperm cells begin to deteriorate
Treatment and nursing care
Occasionally, spontaneous descent of the testis or testes occurs during the first 6 months of life
If this does not happen, treatment is recommended at 9 to 15 months
The testis or testes can be brought down to the scrotum with a surgical intervention called orchiopexy
An inguinal hernia often accompanies this condition.
What psychological issues may be caused by cryptorchidism?
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15. Hypospadias and Epispadias
Description
Hypospadias—the urinary meatus appears on the ventral or underside of the penis’ shaft
Epispadias—the urethral opening is on the dorsal or upper surface of the shaft
Treatment and nursing care
Surgical repair is usually performed between 6 and 12 months of age using the foreskin
Chordee, a downward curvature of the penis, is the result of a tight fibrous band and may be seen with hypospadias.
Why would a ureteral stent be placed during surgery?
Fluid intake is important, and increased amounts are necessary to decrease the risk for infection.
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16. Dysmenorrhea (Primary)
Description
Painful menstruation; denotes pain associated with the menstrual cycle in the absence of organic pelvic disease
Secondary dysmenorrhea: Patient may have an underlying condition such as endometriosis, PID, ovarian cysts, adhesions, congenital abnormalities
Mittelschmerz: Midcycle pain during ovulation
What is mittelschmerz?
About two-thirds of postpubescent teenage girls in the United States have some degree of dysmenorrhea.
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17. Dysmenorrhea (Primary)
Signs and symptoms
Cramping, abdominal discomfort, and leg aches, all of which begin at the onset of menses
Systemic symptoms such as nausea, vomiting, dizziness, diarrhea, backache, and headache
Premenstrual syndrome: symptoms overlap with dysmenorrhea, but include weight gain, breast tenderness, irritability, and insomnia
Treatment and nursing care
Ibuprofen or naproxen should be taken every 4 hours; usually 2 to 3 days of medications are required
Warm heating pad applied to the lower abdomen
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18. Sexually Transmitted Diseases
Chlamydia infection
Most common STD in the U.S.
Often asymptomatic
Gonorrhea
Anaerobic bacterium
GC, clap, a dose, strain, the drip
Men: Symptoms within 2-7 days of contact
Painful urination, pus discharge, inflamed scrotum
Women: 80-90% asymptomatic
Mild burning in genital area, possible yellow discharge, swelling of Bartholin glands, abdominal discomfort. Can cause PID.
Minors can receive free, confidential treatment without parental consent from the city/state health department, or most physicians
Chlamydia: should an infected woman give birth vaginally, the infant is at risk for development of neonatal conjunctivitis and pneumonia.
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19. Sexually Transmitted Diseases
Syphilis
Caused by spirochete Treponema pallidum
Can be passed to unborn children
Incubation period: days
Stages of syphilis symptoms
Primary: chancre sores where spirochete enters the body
Secondary: begins 4 weeks to 6 months after infection. Disease enters a latent period if left untreated
Tertiary: After the fourth year. Spirochetes attack heart, blood vessels, brain, spinal cord
Insanity and blindness, crippling or paralysis, death
Generally, syphilis is not contagious after the first 2 years.
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20. Sexually Transmitted Diseases
Genital herpes
Herpes simplex virus (HSV) type II frequency among teenagers is increasing
Lesions can persist for 3-6 weeks
Fever, headache, malaise, anorexia
HSV Type II can be passed to infants via the birth canal
Cesarean section is generally performed
There is no known cure for genital herpes.
Herpes is thought to be a predisposing factor in cancer of the cervix.
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.

21. Sexually Transmitted Disease
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.

22. Sexually Transmitted Diseases
Treatment and nursing care
Hospitalization is uncommon
Nurses need to create a comfortable environment and approach teenagers without judgment
The reporting of sexual contacts, required by law, often prevents patients from seeking help; assuring confidentiality is important
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23. Acquired Immunodeficiency Syndrome (AIDS)
Signs and symptoms
Failure to thrive, chronic diarrhea, repeated respiratory infections, oral candidiasis, and enlargement of the liver and spleen
Treatment and nursing care
There is no cure for AIDS
Several antiviral drugs are being used for treatment in children
Assessment for signs of infection, including vital signs, and observation of the skin and general condition of the child should be done routinely
Due to immune suppression, signs of inflammation/ infection may be suppressed
Psychological support of the child and family is critical
How do the majority of children affected by AIDS contract the virus?
Pregnant women at greatest risk for carrying this disease are intravenous drug users and those with multiple sexual partners.
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.