Child Final Study Guide 2015
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Transcript of Child Final Study Guide 2015
Child Health Final
Child Development: Chapters 1,5,6,21 &22 (3 questions)
General Trends in Height & Weight Gain During childhood Birth weight doubles by the first 4-7 months Birth weight triples by end of the first year Birth weight quadruples by the age of 2.5 years Birth height increases by 50% by end of 1st year Height at age 2 years is about 50% of eventual adult height
How to help them with the milestone
Erickson’s Stages:Trust vs. mistrust (0-1 years)Autonomy vs. shame and doubt (1-3 years)Initiative vs. guilt (3-6 years)Industry vs. inferiority (6-12 years)Identity vs role confusion (12-18 years)
Role of Play In Development Content of Play
o Social-affective Play Infant takes pleasure in relationships with people
o Sense Pleasure Play Nonsocial stimulating experience that originates from objects
in the environment. Anything that can stimulate their senses o Skill play
Repeating an action over and over againo Unoccupied behavior
Focusing attention momentarily on anything that strikes their interest
o Dramatic/Pretend Play Begins in late infancy (11-13 months). Is the predominate
form of play in preschool childreno Games
Imitative games: pat-a-cake Formal games: ring-around-a-rosy Competitive games: board games
Social Character of Play o Onlooker Play
Children watch what other children are doing, but do not enter into play
o Solitary Play Interest is centered on their own activity. Play with toys alone,
different from those used by others in their same areao Parallel Play
Children play independently but among other childreno Associative Play
Children play together and are engaged in a similar or even identical activity, but there is no organization, division of labor, leadership assignment or mutual goal
o Cooperative Play Play is organized, and children play in a group with other
children…there is a goal for this type of play
Chapter 6 focuses on assessing a Child and How to communicate with themHow to administer medication?Nutrition: breast milk (no feeding until feed they start siting up); if breastfeed they need iron and vitamin D.
DO WE NEED TO KNOW PIAGET COGNITIVE THEORY? PAGE 71 (Maybe? She does not remember if there are Piaget questions on the final)
Infectious disorders/Communicable Diseases: Chapters 14 (2 questions)
Communicable Disease: Identification of the infectious agent is of primary importance to prevent exposure of
susceptible individuals Prodromal symptoms = symptoms that occur between early manifestations of the disease
and its overt clinical syndrome Can be prevented through immunizations and hand-washing, as will as standard precautions
Nursing Alert: If a child is admitted to the hospital with an undiagnosed exanthema (skin eruption) strict
Transmission-Based Precautions (Contact, Airborne, and Droplet) and Standard Precautions are instituted until diagnosis is confirmed. Childhood communicable disease requiring these precautions include: diphtheria, chickenpox, measles, TB, adenovirus, Haemophilus influenza type b, influenza, mumps, Mycoplasma pneumonia infection, pertussis, plague, strep pharyngitis, pneumonia, and scarlet fever.
When lotions with active ingredients such as diphenhydramine in Caladryl are used, they are applied sparingly, especially over open lesions, where excessive absorption can lead to drug toxixity, Use these lotions with caution in children who are simultaneously receiving an oral antihistamine. Cooling the lotion in the refrigerator beforehand often makes it more soothing on the skin than at room temperature.
Chicken Pox:Transmission:
Direct Contact, droplet airborne spreadClinical Manifestations
Prodromal Stage
o Slight fevero Malaiseo Anorexiao Rash highly pruritic (begins as macule papule vesicle)
Distributiono Centripetal spreads to face and proximal extremities (sparse on distal limbs and
areas exposed to less heat) Constitutional s/s
o Fevero Irritability from pruritus
Nursing Consideration/Treatment Airborne and contact precautions (negative air pressure room) Keep child at home until vesicles have dried and crusty (usually 1 week after onset) Incubation 2-3 weeks Give bath and change clothes and linens daily Administer topical calamine lotion (intact or dried lesions) Keep child’s finger nails short and clean-apply mittens if child scratches Teach child to apply pressure to itchy area instead DO NOT use Aspirin Childhood Immunization for prevention Make give acyclovir to someone to prevent it from them getting it really bad
Measles (Rubeola): ** Transmission:
Direct contact, with droplets of infected person Airborne
Clinical Manifestations: Prodromal (catarrhal) stage
o Fevero Malaise in 24 hours followed by
Coryza Conjunctivitis Koplik Spots (small irregular red spots with minute, bluish white center
first seen on the mucosa) Symptoms gradually increase until second day after rash appears
Rasho Appears 3-4 days after onset of prodromal stageo Starts on face then spreads downwardo After 3-4 days assumes brownish appearance and fine desquamation occurso Isolation until 5th day of first appearso 4 days prior to rash
Constitutional s/so Anorexiao Abdominal paino Malaiseo Generalized lymphadenopathy
Nursing Considerations/Treatment Airborne precautions Isolation until 5th day Rest Antipyretics for fever Eye care
o Dim lights if photophobia is present
o Clean eyelids with warm saline to remove secretions or crusto Do not rub eyes
Coryza, cougho Cool mist vaporizero Petrolatum layer around nares to protect skino Fluids and soft bland foods
Skin careo Clean, use tepid baths prn
Prevention: Childhood immunization and Vitamin A supplementation
Erythema Infectiosium Transmission
Respiratory secretions and bloodClinical Manifestations
Rash appears in 3 stageso Stage 1
“Slapped face” on the cheeks Leaves within 1-4 days
o Stage 2 Maculopapular red spots appear, symmetrically distributed in upper and
lower extremities Proximal distal
o Stage 3 Subsides, but reappears with sun, heat or cold
Nursing Considerations/Treatment Isolation only needed if child is hospitalized or with aplastic crisis Respiratory isolations if in hospital NO pregnant females Antipyretics, analgesics and anti-inflammatory drugs After they break out of rash, they are not contagious
Rosella Infantum Transmission
o Possibly acquired from saliva of health adult…no reported contact with infected o Incubation 5-15 days o Limited to children <3 years of age
Clinical Manifestationso Persistent high fever, while child appears wello Rash
Discrete rose-pink macules or maculopapules 1st on TRUNK spread to NECK, FACE and EXTREMETIES
Nonpruritic Fades on pressure (blanchable) Last 1-2 days
o Associated S/S Cervical and post auricular lymphadenopathy Inflamed pharynx Cough coryza
Nursing Considerations/Treatment
o Teach parents measures to reduce fever, and dosage on antipyretics to prevent overdose
o If child is prone to seizures , discuss appropriate precautions and possibility of recurrent febrile seizures.
MumpsTransmission:
Direct contact with or droplet spread from an infected person Agent: paramysovirus Saliva from infected person Incubation 2-3 weeks
Clinical Manifestations: Fever Headache Malaise Followed by parotitis
Nursing Considerations/Treatment: Droplet and Contact Precautions; maintain isolation during period May cause orchitis and meningoencephalitis Encourage rest and decreased activity until swelling subsides Encourage fluids and soft bland diet foods, avoid chewing Apply hot or cold compresses to neck To relieve orchitis provide warmth and local support with tight fitting underpants
(can lead to sterility for males) Painful for them to chew
German Measles (Rubeola ) Agent: Rubella virus 3 day measles (kids recover during 3 days) Droplet precautions Avoid contact with pregnant women Vaccine given at 15 months
Clinical Manifestations Prodromal Stage
o low grade fevero headacheo malaiseo anorexiao mild conjunctivitiso coryzao sore throato cough
Rasho 1st appears on face rapidly appears downward to neck, arms, trunk, legso By the end of first day, body – disappears in the same order it began
Nursing Consideration/Treatment Droplet precautions Antipyretics and analgesics Child should be completely recovered in 3-4 days Avoid contact with during pregnancy (teratogenic effect on fetus)
The child receives the immunization NOT the mother
Scarlet Fever Group A strep Droplet Precautions until 24 hours after initiation Incubation period: 3-5 days (with symptoms beginning on the 2nd day) Complications: Peri-tonsillar and retropharyngeal abscess & carditis Rash appears within 12 hrs everywhere, except face
Clinical Manifestations Abrupt high fever Increased pulse Vomiting Headache Chills Malaise Abdominal pain Halitosis First day: white strawberry tongue Third day: Red Strawberry tongue
Nursing Considerations/Treatment Antibiotics Encourage rest during febrile time Relive discomfort of sore throat with analgesics, gargles, lozenges antiseptic throat sprays and cool mists Encourage fluid intake Begin with sift diet when child can eat Discard toothbrush, avoid sharing drinks and eating utensils The child receives the
Conjunctivitis (Pink Eye) Pink eye is caused by many things In NBs chlamydia, gonorrhea, or Herpes Infants can by sign of tear duct obstruction Infections and is HIGHLY CONTAGIOUS
Clinical Manifestations Itching Purulent drainage Inflamed Conjunctivitis Crusting eyelids
Nursing Considerations Keep eye clean Remove accumulated secretions wiping the inner canthus downward and outward away from the opposite eye Warm, moist compresses, such as clean washcloth wrung out with hot tap H2O Instill medication after cleansing eye Instruct the child to refrain from rubbing the eye and to use good hand-washing technique
NURSING ALERT Signs of serious conjunctivitis include reduction or loss of vision, ocular pain, photophobia, exophthalmos (bulging eyeball), decreased ocular
mobility, corneal ulceration, and unusual patters of inflammation. Refer patient to HCP if they have any of these signsStomatitis
Caused by Herpes virus Inflammation of the oral mucosa May be infectious or non-infectious May be caused by local or systemic factors. Canker Sore Cold Sores or Fever Blisters
Treatment Management: Relief & prevention of the spread of Herpes Virus
Good hand washing is a must! Wear gloves when examining lesions.
Health Promotion: Chapter 10,12,16 & 17 (10 questions) (LOOK AT) Health promotion and problems of different age groups
Milestones: Look at TABLE 10-1 page 310-314Also look at the infant separation/anxiety and stranger fearTeethingDiscipline (box pg33)Injury preventionImmunizations (know which ones to give at what age)
Disorder Pathophysiology Clinical Manifestation Treatment/TeachingADHD Developmentally
inappropriate degree of inattention, impulsiveness and hyperactivity
Hyperactive BOX 17-2 on page 502 has
the diagnostic criteria
Drug therapy; Methyphenidate
hydrochloride (Ritalin) Dextoamphentamine
sulfate (Dexedrine) Began on a small dosage
that is gradually increased Must be assessed every 6
months for appropriate growth and development milestones
Require a more structured environment than most children
The nurse should help families identify new appropriate contingencies and reward systems to meet the child’s developing needs
Encourage consumption of nutritious snacks in the evening when the effects of the medication are decreasing, and serving frequent small meals with healthy “on the go” snacks are helpful interventions
Sleeplessness is reduced
by administering medication early in the day
Avoid caffeine because decreases the efficacy of the drug
Chronic Illness in Children: Chapter 18 (2 questions)
Impact of Child’s Chronic Illness or disabilityPage 540BOX 18-4 page 542 – Supporting siblings of children with special needs
The child with special NeedsBOX 18-6 (Coping Patterns Used By Children with Special Needs (page 545)
The child who is terminally ill or dyingPage 540 BOX 18-2 adaptive tasks of parents having children with chronic conditions
Cognitive Disorders: Chapter 19 (2 questions)Cognitive Impairment (page 572)Down Syndrome (Page 577)
Respiratory Disorders: Chapter 23 (5 questions) (LOOK AT)
Disease Pathophysiology Clinical Manifestations Treatment/ TeachingNasopharyngitis Aka the common cold
Rhinovirus (winter & spring)Younger children Fever
Managed at home Antipyretics
Irritability Restlessness Poor feeding and decrease
fluid intake Nasal mucus V/DOlder children Dryness & irritation of nose &
throat Nasal d/c Sneezing Muscle aches CoughPhysical Assessment: Edema Vasodilation of the mucosa
Rest Decongestants & cough
suppressants DO NOT GIVE if <6 years (For decongestants the book actually says you can give, but be cautions for children over 12 months, so she said she wont ask a question about it)
Elevate the HOB Suctioning and vaporization
(saline nose drops & gentle suction with a bulb syringe before feeding and sleep time maybe useful
Increase fluids Infection of control (proper
PPE) Prevention: avoid contact with
infected person, and hygiene Parents are instructed to notify
HCP if any of the following s/s Refusal to take oral fluids and
decreased urination Evidence of earache Respirations faster than 50-
60 bpm in a toddler or older child
Persistent cough or exacerbating cough
Wheezing Restlessness and poor sleep
patterns
Nursing Alert Parents are cautioned
regarding OTC combination “cold” remedies because these often include acetaminophen. Careful calculation of both the acetaminophen given separately and the acetaminophen in combination medications is necessary to avoid an overdose
Laryngotrachesobronchitis Part of the croup syndrome Affects children <5 years Cause by Para-influenza, RSV
and influenza A&B Inflammation of mucosa lining
of the larynx and trachea causing narrowing of the airway
Will go to bed and wake up with a bad cough
Slowly progressive Stridor Suprasternal retractions Barking or seal-like cough Increasing respiratory distress
and hypoxia Can progress to respiratory
acidosis, respiratory failure, and death
NURSING ALERT: Early signs of impending
airway obstruction include increased pulse and respiratory rate; substernal and intercostal retractions; flaring nares and increased restlessness
Cold humidify air
Airway maintenance is priority
Providing adequate respiratory exchange
Maintain hydration (PO or IV) Watch for dehydration: Weigh diaper over a 24 hour
period Should be 1mL/kg/hr. > 6 months, >30kg should be
30 mL/hr. High humidity with cool mist Oxygenation status thru pulse
oximetry Nebulizer treatments: Epinephrine Steroids (IM prefer) slow
release from muscle tissue vs. oral they with clear a lot fater
Pharyngitis Strep throat “GABHS” At risk for rheumatic fever &
acute glomerulonephritis
Younger children Fever General malaise Dysphagia Abdominal painPhysical assessment: Mild-to-moderate-hyperemia
Older children Fever (may reach 40C 104 F) Headache Anorexia Dysphagia Abdominal pain VomitingPhysical Assessment; Mild to bright red, edematous
pharynx Hyperemia of tonsils and
pharynx, may extended to soft palate and uvula
Often abundant follicular exudate that spreads and coalesces to form pseudomembrane on tonsils
Cervical glands enlarged and tender
Throat culture to rule out GABHS
If streptococcal infection is present oral penicillin is prescribed, erythromycin for children allergic to PCN
Obtain a throat swab culture Instruct parents on
administering antibiotics, Cold or warm compresses to
the neck, Warm saline gargles Manage pain with
acetaminophen or ibuprofen Offer cool liquids or ice chips Children consider infectious
to others at the onset of symptoms and up to 24 hours after the initiation of antibiotic therapy, replace toothbrush after have been taking antibiotics for 24 hours
DRUG ALERT Never administer Penicillin
via IV, it may cause an embolism, or toxic reaction w/insuring deaths in minutes instead administer IM to decrease localized reaction and pain.
Epiglottitis Serious obstructive inflammatory process that occurs predominantly in
3 predictive observations: Cough Drooling
NURSING ALERT: Throat inspection should be
attempted only when
children 2-5 yrs. Caused by H influenza Abrupt onset Emergency NEEDS for ASAP
Agitation
Child goes to be asymptomatic to awaken later complaining of sore throat and pain on swallowing
Stridor (aggravated when supine)
High fever Rapid pulse and respiration Tripod position
immediate endotracheal intubation can be performed
When epiglottis is suspected the nurse should not attempt to visualize epiglottis directly with tongue depressor or take a throat culture but refer to the child for medical evaluation
Start IV infusion Continuous monitoring of
respiratory status and pulse oximetry
ABGs if child is intubated Prevention HIb vaccine
Croup Syndrome Affect larynx, trachea bronchi Ie. Are epiglottis, laryngitis,
larngotracheobronchitis (LTB) and tracheitis
Hoarseness Barking cough Inspiratory stridor
RSV (AND BRONCHOLITIS) Respiratory syncytial virus. Most common cause of bronchiolitis
RSV affects the epithelial cells of the respiratory tract. The ciliated cells swell, protrude into the lumen, and lose their cilia
Bronchiolar mucosa swells and lumina are subsequently filled with mucus and excaudate walls of the bronchi and
Initial: Rhinorrhea (1st) Pharyngitis Cough, sneezing Wheezing Possible ear or eye drainage Intermittent fever (1st)
With progression of illness: Increased coughing and
wheezing Tachypnea and retractions cyanosis
Treat the symptoms Contact precautions
bronchioles are infiltrated Intraluminal obstruction leads
to : Hyperinflation Emphysema Atelectasis
Severe illness: Tachypnea >70 bpm Listlessness Apneic spells Poor air exchange Poor breath sounds
Asthma Chronic inflammation disorder of the airways
Characterized by: Recurring symptoms Airway obstruction Bronchial hyper-
responsiveness
Dyspnea Wheezing Coughing
TX Short acting medication:
B2 agonist Anticholinergic Systemic corticosteroids
Long acting medication: Inhaled corticosteroids Cromolyn sodium &
nedocromil Long acting b2 agonist Methylxanthines Leukotrines modifiers
Cystic Fibrosis Inherited autosomal recessive trait
Mechanical obstruction caused by the increased viscosity of mucous gland secretions
Affects other organs
Meconium ileus Abdomen distention Vomiting Failure to pass stool Rapid development of
dehydrationGI Large, bulky, loose, foul
stool Eat a lot (early in disease) Lose appetite (later in
disease) Weight loss
Diet: High caloriecdiet with high fat
Treat and prevent pulmonary infections
Flutter muscu clearance device
High frequency chest compression
Broncholdilator medication Replacement of pancreatic
enzymes given with meals and snacks (take extra enzymes when high fat
Marked tissue wasting Failure to grow Distended abdomen Thin extremities Yellow or pale brown skin Deficient in vitamins A, D,
E, K anemiaLungs Wheezing Dry non-productive cough Increased dyspnea Paroxysmal cough Obstructive emphysema and
patchy areas of atelectasis Barrel-shaped chest Cyanosis Clubbing Bronchitis and
bronchopneumonia
foods are eaten)NURSING ALERT Signs of pneumothorax
are usually nonspecific and include tachycardia, dyspnea, pallor, and cyanosis. A subtle drop in O2 saturation (increased by pulseoximetry) may be a early sign of pneumothorax
Medications associated with respiratory dysfunction (action & adverse effects):
SIDS-pg 401:
GI Disorders: Chapter 24 (5 questions)
Disease Pathophysiology Clinical Manifestation Therapeutic ManagementHirschsprung Disease
Congenital abnormality Results in obstruction
Table 24-3 NB
Surgery Removal of the aganglion portion of the
from inadequate motility of part of the intestine
Aka: aganglionicmegacolon Mutations of RET proto-
oncogene have been found
In the majority of cases aganglionosis is restricted to the internal sphincter, rectum and part of the sigmoid colon
Absence of ganglion cells in the intestines that results in loss of rectosphincteric reflex and an abnormal microenvironment of cells of the affected intestine
Absence of these cells results in a lack of enteric nervous system stimulation, which decreases the internal sphincters ability to relax
Contraction of abnormal bowel
Lack peristalsis Loss of rectosphincteric
Failure to pass meconium within 24-48 hours
Refusal to feed Biolous vomiting Abdominal distention Infancy Growth failure Constipation Abdominal distention Episode of diarrhea and
vomiting Signs of enterocolitis:
explosive, watery diarrhea, fever, appears significantly ill
Childhood Constipation Ribbon-like, foul smelling
stools Abdominal distention Visible peristalsis Easily palpable fecal mass Undernourished anemic
appearance
bowel to remove obstruction, restore normal motility and preserve function of external sphincter
Soave endorectal pull-through: pulling the end of the normal bowel through the muscular sleeve of the rectum; Complication: constipation (enterocolitis) and fecal incontinence
Diet low in fiber, high calorie, high protein
Anorectal myomectomy: for very short segment diseases
Prior to surgery child is stabilized with fluid and electrolyte replacement
Preop Make sure that physical status is good, if not
treat with enemas; a low fiber, high calorie and high protein diet or TPN in severe cases
Decrease bacterial flora with antibiotics and colonic irrigations using antibiotic sol’n
In children: empty bowels with saline enemas and decrease bacterial flora with oral or systemic antibiotics and colonic irrigations (bowel cleansing)
Emergency preop care includes: monitor vital signs for signs of shock, fluid, electrolyte replacement, plasma or blood derivatives and observe for symptoms of bowel perforation such as fever, increasing
reflex abdominal distention, vomiting increased tenderness, irritability, dyspnea and cyanosis
Infants: no prep needed Measure abdominal circumference with a
paper tape measure (level of umbilicus or widest part of abdomen; can leave the tape measure underneath the child)
2 step process to let the abdomen rest (only if it is really distended, the mega-colon you need to allow it to undisteneded
Post-op: Stoma care when there is a colostomy To prevent contamination of an infants
abdominal wound, place diaper below dressing
A Foley catheter may be placed to divert urine away from abdomen
Listen for bowel sounds, make sure they are passing gas
Discharge care Teach parents about colonostomy care
Cleft lip or Cleft Palate
Facial malformation that occurs during embryonic development
Most common congenital deformities
Clefts of the lip (CL) and palate (CP) can occur alone or together
Most are caused by
Apparent at birth Sometimes seen on
ultra sounds
Surgical correction of Cleft Lip Occurs 2-3 months Rule of “ten:” 10 weeks old, 10lbs, hgb of 10 Tennison-Randall triangular flap (Z plasty) Millard rotational advancement technique Nasoallveolar may be used to bring cleft
segments together prior to surgery Surgical Correction of Cleft Palate Occurs between 6-12 months
genetics and environmental factors
Exposure to teratogens such as alcohol, cigarette smoking, anticonvulsants, steroids and retinoids are associated with higher risk
The severity of CP has an impact on feeding; the infant is unable to create suction in the oral cavity that is necessary for feeding (ability to swallow is normal)
Veau Wardill-Kilner VY pushback procedure Furlow double opposing Z plasty May need a 2nd surgery to improve
velopharyngeal for speech. Nursing teaching highest priority is
learning how to feed their infants and CL may interfere with the infant’s ability to
achieve an adequate anterior lip seal; no difficulty breastfeeding, use wide based bottles
CP reduces the infant’s inability to suck, which interferes with breastfeeding and traditional bottle feeding
Positioning in an upright position, with head supported by caregivers hand when feeding
Suction is impaired in infants with CP, using the specific bottles that like Special Needs Feeder, Pigeon Bottle, etc,
Infants with clefts tend to swallow excessively, so it is important to pause during feedings and burp infant
Preop Teach parents how to use alternative
methods for feeding ie syringe Postop Protecting op site For CL use petroleum jelly For CL, CP or CL/P elbow immobilizers may
be used to prevent the infant from rubbing the suture line (applied after surgery-
7/10days) Recommendation of syringe for feeding Analgesia for pain and to prevent
restlessness Feeding resumed when tolerate Upright or infant seat position is helpful Avoid the use of suction or other objects in
mouth: tongue depressors, thermometers, pacifiers, spoons, or straws
Older child: blenderized or soft diet; no toast, hard cookies, and potato chips
Long Term Speech therapy Development of healthy personality and
self-esteem Tooth problems, so they will need to see a
orthodonticsEsophageal Atresia with Tracheoesophageal
Rare malformations that represent a failure of the esophagus to develop as a continuous passage and the trachea & esophagus to separate into distinct structures
Can occur alone or both Cause is unknown When a mother had
polyhydraminose (excessive amnioc fluid in sac), that’s when you
Box 24-9 Excessive frothy
mucus from nose and mouth
3 Cs of tracheoesophageal fistula:
Coughing Choking Cyanosis Apnea Increased
respiratory distress
As a nurse, if you suspect this you will be there for the 1st feeding and administer water in a medicine cup to look for the 3Cs
If its there stop giving them the water baby stays NPO and
As a nurse you want to maintain patent airway, prevention of pneumonia, gastric blind pouch decompression, supportive therapy and surgical repair of anomaly.
When EA with TEF is suspected, the infant is immediately deprived of oral intake, IV fluids are initiated and the infant is positioned to facilitate drainage of
would suspect it during feeding Abdominal
distention Suspected in cases of
polyhydramnios (excessive fluid in the amniotic sac)
secretions and decrease the likelihood of aspiration
Mouth and pharynx suctioned frequently because of accumulated secretions
Double-lumen catheter placed into the upper esophageal pouch and attached intermittent or continuous low suction
Infants head kept upright (30degrees) to help with removal of fluid collected in the pouch and prevent aspiration of gastric content
Antibiotics if there is concern of aspiration of gastric content
Surgery: thoracotomy for infants who are not stable enough 2
stages: 1) involves gastrostomy, ligation of the TEF and constant drainage of esophageal pouch 2) esophageal anastomosis done weeks later
Thorascopic repair of EA/TEF If tracheomalacia is present (when dilated
proximal pouch compresses the trachea early in fetal life), surgical intervention would be aortopexy or stent replacement. Clinical manifestation are: barking cough, stridor, wheezing, recurrent respiratory tract infections, cyanosis and sometimes apnea
NURSING ALERT: Any infant who has an
excessive amount of frothy saliva in the mouth or difficulty with secretions and unexplained episodes of apnea, cyanosis or oxygen desaturation should be suspected of having an EA or TEF and referred and referred immediately for medical evaluation.
Preop Nursing interventions include: respiratory
assessment, airway management, thermoregulation, fluid and electrolyte management and PN support
Suctioning Positioning: preferably supine (sometimes
prone) with head elevated on an inclined at least 30 degrees. This helps minimize reflux of gastric secretions at the distal esophagus into the trachea and bronchi
Until surgery the blind pouch is kept empty by intermittent or continuous suction through an indwelling catheter passed orally or nasally
Postop Infant returned to radiant warmer or
isolette Double-lumen catheter is attached to low-
suction or gravity drainage PN is provided Gastrostomy tube (if they have one) is
returned to gravity drainage until feeding is tolerated
24-36 pain management Tracheal suction
only done using a premeasured catheter with extreme caution to avoid injury to the suture line Make sure infant is able to swallow without
feeding Special problems Problems such as pneumonia, atelectasis,
pneumothorax and laryngeal edema Respiratory difficulty reported ASAP Monitored for anastomotic leaks as
evidence by purulent drainage, chest tube drainage, increased WBCs and temperature instability
Esophagestomy: care for skin because it becomes irritated by moisture from the continuous discharge of saliva. Frequent removal of drainage and application of layer protective ointment may remedy the problem Esophageal replacement, nonnutritive
sucking is provided by a pacifier, to allow the infant to develop mature sucking patterns
Some patients with EA/TEF require periodic esophageal dilation on an outpatient basis
Tracheomalacia is a complication
Hypertrophic Pyloric Stenosis
Occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel
It produces an outlet obstruction and compensatory dilation, hypertrophy and hyperperistalsis of stomach
Develops first 2-5 weeks of birth
Causes projectile vomiting, dehydration, metabolic alkalosis and growth failure
Genetic predisposition Circular muscle of the
pylorus thickens as a result of hypertrophy and hyperplasia (increased mass). This produces sever narrowing of the pyloric
Box 24-11 Projectile vomiting May be ejected 3-4 ft from
child when in a side-lying position or 1 foot when in supine position
Occurs shortly after feeding, but may not occur for several hours
Nonbilious vomitus that may be blood tinged
Infant hungry, avid feeder, eagerly accepts a second feeding after vomiting episode
No evidence of pain or discomfort other than hunger
Weight loss or failure to gain weight
Signs of dehydration Distended upper abdomen Readily palpable olive-
shaped tumor in epigastrium just to the right of the umbilicus
Visible gastric peristaltic
Preop Restoring hydration and electrolyte balance,
metabolic alkalosis must be corrected NPO receive IV fluids with glucose and
electrolyte replacement Assess: Vital signs, skin mucous membranes,
and daily weight Stomach decompress with an NG tube, the
nurse must ensure the tube is patent and functioning properly. Also responsible for measuring and recording the type and amount of drainage
Postop IV fluids administered until the infant is
taking and retaining adequate amounts by mouth
Monitoring same things that were assessed Observed for responses to the stress of
surgery and for evidence of pain Surgical incision is inspected for drainage or
erythema and any signs of infection, report ASAP
Feedings usually being 4-6 hours post-op Teach parents how to care for incision Observation and feeding recordings are
important
canal between stomach and duodenum, causing partial obstruction of lumen
waves that move from left to right across the epigastrium
Intussusception Children ages 3months-3years
Common in children with cystic fibrosis
Unknown cause Occurs when one
segment of the bowel telescopes into another segment, pulling the mesentery with it
The mesentery is compressed and angled resulting in lymphatic and venous obstruction
As edema from obstruction increases pressure increases. When pressure equals arterial pressure, arterial blood flow stops results in ischemia and pouring of mucus into the intestine + leaking of blood and mucus into intestinal lumen resulting in currant
Sudden acute abdominal pain
Child screaming and drawing knees into chest
Child appearing normal and comfortable between episodes of pain
Vomiting Lethargy Passage or red, current
jelly-like stools (mixed with blood and mucus)
Tender, distended abdomen
Palpable sausage-shaped mass in upper right quadrant
Empty lower right quadrant (dance sign)
Eventual fever, prostration and other signs of peritonitis
Fetal position in pain
Assess children with severe colicky abdominal pain combined with vomiting, which is a significant sign
NURSING ALERT: The classical traid s/s: abdominal mass, abdominal pain, and bloody stools. Children might initially be seen screaming, irritable, lethargy, vomiting, diarrhea or constipation, fever, dehydration and shock. Can be life threatening, the nurse should be aware of alternative presentations, observe the child closely, and refer them for further evaluation.
Treatment consists of radiologist-guided pneumonia (air enema) with or without water-soluble contrast or ultrasound guided hydrostatic (saline) enema.
IV fluids , NG decompression and antibiotic therapy may be used before hydrostatic reduction
Laparoscopic surgery that involves manually reducing the invagination and when indicated, resecting any nonviable intestine
Look at stool, if stool is normal then no further procedure; however, if stool remains jelly-bloody like then surgery is required
jelly-like stools NURSING ALERT: Passage of normal brown stool usually indicates that intussusception has reduced itself. This is immediately reported to the HCP, who may chose to alter the dx and therapeutic care plan.
Preop NPO Lab test: CBC and urinalysis Pre-anesthetic sedation Nurse monitors all stoolsPost-op Assess: vital signs, sutures and dressings,
return of bowel sounds After hydrostatic reduction the nurse
observes passage of water soluble contrast material and stool patterns; reoccurrence is possible
Reoccurrence is treated with conservative reduction techniques
Celiac Disease Characterized by villous atrophyin the small bowel in response to the protein gluten
It is a permanent intestinal intolerance to dietary wheat gliadin and related proteins that produces mucosal
Impaired Fat absorption Steatorrhea (excessively
large, pale, oily, frothy stools
Exceeding foul-smelling stools
Impaired nutrient absorption
Corn and rice become substitute grain foods Advise child and patients to read labels
carefully Diet requires a wheat-barley, and rye free
diet A diet high in calories and proteins with
simple carbohydrates such as fruits and vegetables, but low in fat
lesions in genetically susceptible individuals
Exact cause is unknown, accepted that it is an immunologically mediated small intestine enteropathy
Gluten is found in wheat, barley, rye and oat grains
When individuals are unable to digest the gliadin component of gluten, an accumulation of toxic substance that is damaging to the mucosal cells occur
Damage to the mucosal of the small intestine leads to villous atrophy, hyperplasia of the crypts, and infiltration of the epithelial cells with lymphocytes
Villous atrophy leads to malabsorption caused by reduced absorptive
Malnutrition Muscle wasting (especially
prominent in legs and buttocks)
Anemia Anorexia Abdominal distention Behavioral changes Irritability Uncooperativeness Apathy Celiac crisis: Acute, sever
episodes of profuse watery diarrhea and vomiting. May be precipitated by:
Infections (especially GI) Prolonged fluid and
electrolyte depletion Emotional disturbance
Avoid high fiber foods, such as: nuts, raisins, raw vegetables and raw fruits with skin until inflammation has subsided
surface area Genetic predisposition
Congenital/cardiac Disorders: Chapter 25 (6 questions)
Pathophysiology Clinical Manifestations Nursing Consideration/Teachings
Congestive Heart Failure Inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filing pressures to meet demands
In children, it occurs secondary to structural abnormalities that result in increased blood volume and pressure within the heart
Right-sided failure = R ventricle is unable to pump blood effectively into the pulmonary artery, resulting in increases pressure in the R atrium and systemic venous circulation
Left-sided-failure = L ventricle is unable to pump blood into the systemic circulation, resulting in increases pressure in the L atrium and pulmonary veins. The lungs become
Impaired Myocardial Function Tachycardia Sweating Decreased urinary output Fatigue Weakness Restlessness Anorexia Pale, cool extremities Weak, peripheral pulses Decreased BP Gallop rhythm Cardiomegaly
Pulmonary Congestion Tachypnea Dyspnea Retractions (infants) Flaring nares Exercise intolerance Orthopnea Cough, hoarseness Cyanosis Wheezing
Administer digoxin. But first check the apical pulse. Do not administer if to an infant if the pulse is <90-110 bpm; and young children if the pulse is <70 bpm
Monitor afterload reduction by measure BP before and after ACE administration
Assess serum electrolytes and renal function
Clustering treatment to minimize unnecessary stress
Monitor temperature because hyperthermia or hypothermia because it increases the need for oxygen
Skin breakdown from
congested with blood, causing elevated pulmonary pressures and pulmonary edema
GruntingSystemic Venous Congestion Weight gain (best way to
determine HF in child/infant) Hepatomegaly Peripheral edema (especially
periorbital) Ascites Neck vein distention
edema is prevented with a change of position every 2 hours
Reduce Respiratory Distress, through careful assessment, positioning and oxygen administration which can reduce respiratory distress
Antibiotics given to reduced the chance of getting a respiratory tract infection
The nurse seeks measures to enable the infant to feed easily without excess fatigue and to increase the caloric density of the formula
Assist in measures to promote fluid loss
Endocarditis Is an infection of the inner lining of the heart (endocardium), generally involving the valves
Mainly caused by staph or strep
Onset usually insidious Unexplained fever (low
grade and intermittent) Anorexia Malaise Weight loss Characteristic findings
caused by extra cardiac emboli formation Splinter hemorrhages
(thin black nails) under
Administration of high-doses of antibiotics IV 2-8 weeks
Take blood cultures periodically
Prophylactic antibiotics therapy 1 hour before certain procedure that increase risk
Notify the dentist, if the child gets any dental
nails Osler nodes (red, painful
intradermal nodes found on pads of phalanges)
Painless hemorrhagic areas on palms and soles
Petechiae on oral mucous membranes
May be present Hear failure Cardiac dysrhythmias New murmur or change in
previously existing one
procedure Oral care needs to be
maintained to reduced the chance of bacteremia from oral infection
The nurse teaches that any unexplained fever, weight loss, or change in behavior (lethargy, malaise, anorexia) must be brought to the HCPs attention
Hypoxia A reduction in tissue oxygenation that results from low oxygen saturation and PaO2 and results in impaired cellular processes
Cyanosis Desaturated venous blood Clubbing Hypercyanotic spells Polycythemia (increased
blood cells)
Keep child hydrated Place infant-chest position
when having hypercyantoic spells
Pulmonary hygiene Treat pulmonary infections
aggressivelyKawasaki Disease Acute systemic vacuities of
unknown cause Occur in children in younger
than 5 years of age Initial stage of the illness, is
extensive inflammation of the arterioles, venules and capillaries occurs, causing many of the s/s
Can cause formation of
Child must have fever for more than 5 days along with 4-5 clinical criteria Changes in the extremities:
in the acute phase edema, erythema of the palms and soles; in the subacute phase, periungual desquamation (peeling)
High does of IV gamma globulin (IVGG) along with aspirin and then antiplatelets
Monitor heart function I&O Daily weights Assess for signs of heart
failure Symptoms relief:
coronary artery aneurysms in some children
of the hands and feet Bilateral conjunctival
injection (inflammation) without exudation
Changes in the oral mucous membranes, such as erythema of the lips, oropharyngeal reddening; or strawberry tongue
Polymorphous rash Cervical
lymphadenopathy (one lymph node > 1.5 cm)
Cool clothes Unscented lotions Soft loose clothing Mouth care Clear liquids Soft foods Quiet environment
Teach parents about CPR
Congenital Heart Defects:Defect w/ increased
pulmonary blood flow
Atrial Septal Defect (ASD)
Ventricle Septal Defect (VSD)
Atrioventricular Canal Defect
Patent Ductus Arteriosus (PDA)
Pathophysiology opening in the septum between the atriums
blood from L atrium (high pressure) flows into the R atrium (low pressure) causes flow of oxygenated blood into the R side of heart
Opening in the septum between the ventricles
L-to-R shunt is caused by the flow of blood from L ventricle (high pressure) to R ventricle (low pressure).
Increased pressure in the R ventricle causes the muscle to hypertrophy
Spontaneous closure
Incomplete fusion of the endocardial cushions
Consists of low ASD with a high VSD
A large AV valve that allows blood to flow between all 4 chambers
Most common defect in children with Down Syndrome
Failure of the fetal ductus arteriosus (artery connecting the aorta & pulmonary artery) to close w/in the first week
Allows blood to flow from the Aorta to Pulmonary Artery
This shunt usually closes at 12-72 hours; 2-3 weeks seals shut
most likely occurs during the 1st year of life in children having small or moderate defects (usually by 4 years)
Might be noticed 2-8 weeks
L R shunt Causes an increase
workload of the L side of heart, increase in pulmonary vascular congestion & potentially increase in in R. ventricular pressure and hypertrophy
NSAIDS will cause it to premature closure
Clinical Manifestations Asymptomatic Acyonotic Fatigue easily
Heart failure is common
Acyonotic
Moderate to severe heart failure
If asymptomatic follow child and watch for it to close on its own
Mild cyanosis increases with crying
High risk for pulmonary vascular obstructive disease
Results going from aorta pulmonary artery
Widened pulse pressure
Bounding pulse
Asymptomatic Signs of heart failure Acyontoic May hear a heart
murmur at birth and when they come for a follow up you might not hear anything
Treatment/Teachings Pericardial patch or Darcon patch
Procedures Patient receives low-
Procedures Procedures Indomethacin (ibeuprofen) promotes closure
You don’t want it to
dose of aspirin for 6 months
close in utero only when the baby is born
NSAIDs promote opening, and indomethacin promotes closure
Obstructive Defects Coartatation of the Aorta Aortic Stenosis Pulmonic StenosisPathophysiology Aorta is narrowed
Increased pressure proximal (head and upper extremities)
Decreases distal pressure (body and lower extremities)
Narrowing of aortic valve closer to the ventricles
Causes resistance of blood flow in the L ventricle, and pulmonary vascular congestion (pulmonary edema)
Narrowing of the entrance of the pulmonary artery
Resistance to blood flow causes R ventricular hypertrophy
Can reopen foramen ovale, shunting of unoxygenated blood into the L atrium
Clinical Manifestations Increase BP upper extremities, low BP in lower extremities
Bounding pulses in arms Weak or absent femoral
pulses Cool lower extremities Hear failure signs Since L side is working
harder, it may cause L ventricle hypertrophy
May go unnoticed if the PDA does not close
Leads to heart failureNB Decrease CO (hard for blood
to come out) Faint pulses Hypotension Tachycardia Poor feeding syncapy (pass out)Children Exercise intolerance Chest pain Dizziness when standing for
Asymptomatic Cyanosis Heart failure Decrease of CO (severe
cases) Cardiomegaly
OLDER KIDS: Dizziness Headaches Fainting nosebleeds
a long time Systolic ejection murmur
may be present
Treatment/ Teachings prostaglandin E to keep the PDA open
Balloon angioplasty
If they have severe-moderate they need to avoid competitive or intense sports because it can lead to sudden death
Balloon angioplasy
Balloon angioplasty
Decreased Pulmonary Blood Flow
Pathophysiology Clinical manifestations Treatment/Teaching
Tetraology of Fallot 4 defects in 1 VSD PS Overriding aorta R Ventricular
hypertrophy shunt direction depends on
the difference between pulmonary and systemic vascular resistance
unoxygenated blood to the body
Cyanotic bluespells or tet spells
(knee to chest position) clubbing hypoxia
Blalock Taussing Shunt Different procedures
Mixed Defects (Mixed Blood)
Transposition of the Great Arteries/Great Vessels
Truncus Arteriosus Hypoplastic L Heart Syndrome
Pathophysiology Oxygenated blood goes back and fourth unless there is another defect that allows the blood to go to the other side, the child can be okay for a while
Pulmonary artery leaves the R ventricle
Aorta leaves the R ventricle
Blood ejected from the L and R ventricles enters the common trunk so that pulmonary and systemic circulation are mixed
Blood goes towards the lungs since the pressure in the lungs is lower.
Underdevelopment of L side of heart results in hypoplastic L ventricle aortic atresia
An ASD or patent foramen ovale allows blood to flow from L atrium-to-R atrium and R ventricle-to-out to pulmonary artery lungs aorta systemically
Gives lungs extra blood Pulmonary congestion
Clinical Manifestations Cyanotic Heart failure cardiomegaly
heart failure poor feeding poor growth lung congestion fatigue hypoxemia cyanosis poor growth activity intolerance
Mild cyanosis Signs of heart failure until
PDA closes Once PDA closes
progressive deterioration with cyanosis and decreases CO
Pulmonary congestion
Treatment/Teaching prostaglanding E (keeps it open)
procedure
procedures (preferably within the first month of life)
It is a step procedure, more than 1 procedure will occur
Medications: Digitalis glycosides (digoxin) improve contractility (read page 839 Family-Centered Care for Administering)
o NURSING ALERT: Infants rarely receive more than 1 ml (50 mcg or 0.05 mg) of digoxin in one does; a higher dose is an immediate warning of a dosage error. To ensure safety, compare the calculation with another staff member’s calculation before giving the drug
o Measure the elixir in the dropper and stresses the level mark as the meniscus of the fluid that is observed at eye level.
Angiotensin-converting enzyme (ACE ) inhibitors reduce the afterload on the heart, which makes it easier for the heart to pump
o Monitor BP before and after administration and observe symptoms of hypotension and notify HCP if BP is lowo Careful assessment of serum electrolytes and renal function
Beta-Blockers decrease in heart rate, decreases BP and decreases vasodilationo Monitor BPo Side effects: dizziness, headaches and hypotension
Diuretics eliminate excess H2O and salt to prevent accumulationo Furosemide (Lasix):
Drug of choice Causes excretion of Cl- and K+
o Cholrothizide (Diuril): can cause hypokalemia, acidosis with large doses
o Spironolactone (Aldactone): weak diuretic K+ sparing effect Takes several days to take effect
Clinical Consequences of Congenital Heart Disease
Care of children after Cardiac Interventions Monitor BP Montior
Hematologic Disorders: Chapter 26 (4 questions
Disorder Pathophysiology Clinical Manifestation Nursing ManagementLeukemia (ALL classifications)
Cancer of the lymphoid progenitor, affecting B or T cells
Most common in children 3-7 Overproduction of WBCs, but
count is low These cells do not
deliberately attack, instead cellular destruction happens by infiltration and subsequent competition for metabolic elements
Malaise and Fatigue Fever Bleeding gums Lymphadenopathy Splenomegaly Petechiae Weight Loss Meningitis Anorexia Dyspnea
Use of chemotherapeutic agents: induction therapy, CNS prophylactic therapy, intensification therapy and maintenance therapy
Prepare child and family for dx and therapeutic procedure
Relieve pain, narcotics are adjusted or titrated and administered around the clock for best control of pain
Prevent complication of myelosuprression caused by chemotherapeutic agents:
Infection: secondary to neutropenia; Nurse must use all measure to control transfer of infection, monitored for sites of infection and elevation in temperature, IV antibiotics given; adequate protein-caloric intake provides child with better host defense against infection and increases tolerance of chemo therapy. Use of a private room, restrictions of all visitors and health personal with active infection, and strict, hand-washing technique with an antiseptic solution.
NURSING TIP: The child is not immunized against live viral vaccines (measles, rubella,
mumps) until the immune system is capable of responding appropriately to the vaccine. Most institutions have individual guidelines regarding vaccinations in children undergoing immunosuppressive therapy.
Hemorrhage: prevented or controlled by administration platelet concentrates or platelet-rich plasma; avoid skin punctures, aseptic techniques are used for IM shots, bone marrow injections; Mouth care is important; perennial care due to certain drugs making it more likely to cause ulcerations; avoid injuries that cause bleeding; platelet transfusion during active bleeding episodes
Anemia: due to replacement of bone marrow by leukemic cells; blood transfusion may be necessary during induction therapy
Only experience nurses should administer chemotherapeutic agents, because of the risk of severe cellular damage
NURSING TIP: Chemotherapeutic drugs must be given through a free-flowing IV line. The infusion is stopped ASAP if any sign of infiltration (pain, stinging, swelling or redness at the cannulation site) occurs. When chemo and immunologic agents are given, the child be observed for 20 mintues after the infusion for signs of anaphylaxis (cyanosis, hypotension, wheezing, severe urticarial) Emergency equipment (especially BP monitor
bag valve mask) and emergency drugs (especially oxygen, epi, antihistamine, aminophylline, corticosteroids, and vasopressors) must be available. If reaction is suspected, the drug is discontinued, the IV line is flushed with saline, and the child’s vital signs and subsequent responses are monitored.
Managing problems with Drug Toxicity: N/V: administer antiemetic such as serotonin-
receptor antagonist (ondansetron..); administer antiemetic before chemotherapy
Anorexia: NG tube feeding or parenteral nutrition for significant nutritional problems
Mucosal Ulceration: bland, moist, soft diet, use a sponge toothbrush or cotton-tipped applicator, frequent mouth washes with NS, use local anesthetics or w/out alcohol; Stomatitis dental hygiene; Rectal ulcers prevented by toilet hygiene, stool softeners, avoid rectal thermometers and suppositories to prevent trauma
NURSING TIP: Viscous lidocaine is not recommended for young children; if applied to the pharynx, it may depress the gag reflex, increasing the risk of aspiration. Seizures have been rarely associated with the use of oral viscous lidocaine, most likely as a result of rapid absorption into the bloodstream via the oral lesion.
Neuropathy: stool softeners and laxatives for severe constipation, maintain good body alignment if pt on bed rest use footboard to prevent foot drop, safety measures during ambulation because of parenthesis, soft or liquid diet for jaw pain
Hemorrhagic Cystitis: can be prevented by increases fluids, frequent voiding ASAP when urge arises, administering drug early in the am, and administering mensa (an agent that protects the bladder) as ordered
NURSING TIP: if signs of cystitis occur, such as burning or bleeding on urination, prompt medical evaluation is needed.
Alopecia: warning patient prior, wear a soft cotton cap, hair regrows within 3-6 months
Moon Face: caused by steroid therapy, reassure pt that it will go back to normal once drugs are stopped
Mood Changes: feelings range from well-being and euphoria to depression and irritability
Lymphomas (Hodgkin and Non-Hodgkins Disease
Lymphomas are the 3rd most common group of malignancies in kids and adolescents
A group of neoplastic diseases that arise from the lymphoid and hematopoietic systems
Increased lymph nodes Treatment is chemotherapy for children = Non-HodgkinAnd for Hodgkin’s it is chemo and radiation. Chemo is for children younger than 3 radiation can be used on children older than 3.Similar to treatment therapy above
Divide into two HL –originates in the
lymphocytes and mainly involves the lymph system
Metastasizes to nonnodal or extralymphatic sites: spleen, lover, bone marrow and lungs.
Sickle Cell Disease (SCD) Includes all the those hereditary disorders whose clinical, hematologic and pathologic features are related to the presence of HbS.
SCA is a type of SCD Most common genetic disease
world wide
Pallor, jaundice Splenomegaly Leg ulcers Priapism Delayed puberty Infection Acute pain crisis from
infractions of the lung, kidney, spleen, or femoral head will also have fever
Blindness Stroke Malnutrition
SCD (first 2 years): Dactylitis Severe anemia leukocytosis
Record I&O including IV fluids Child’s weight should be taken on admission to
compare to baseline for evaluating hydration Be aware of signs of ACS and CVA ACS signs:
Wheezing Hypoxia Chest pain Fever Cough Tachypnea
CVS signs: Neurological impairment Paralysis
Vital signs & BP monitor closely for impeding shock
Narcotics given around the clock
NURSING TIP: One simple yet graphic way to
demonstrate the effect of sickling is to roll rounded objects, such as marbles or beads, through a tube to stimulate normal circulation and then roll pointed objects such as screws or jacks, through the tube. The effect of sickling and clumping of the pointed object is especially noticeable at bend or slight narrowing of the tube
NURSING TIP: Advise patient to be particularly alert to situations in which dehydration may be a possibility, such as hot weather, and to recognize early signs of reduced intake such as decreased urinary output (ei. Fewer diapers) and increased thirst.
NURSING TIP: Report signs of the following:ACS Acute chest syndrome:
Sever chest, back or abdominal pain Fever of 38.5 C (101.3 F) Cough Dyspnea, tachypnea Retractions Declining oxygen saturation (oximetery)
CVA cerebrovascular accident
Severe unrelieved headaches Severe vomiting Jerking or twitching of the face, legs or arms Seizures Strange, abnormal behavior Inability to move an arm or leg Stagger or an unsteady walk Stutter or slurred speech Weakness in the hands, feet or legs Changes in vision
Gastriurinary Disorders: Chapter 27 (5 questions)
Disorder Pathophysiology Clinical Manifestation Nursing ManagementUrinary Tract Infection
Predisposing Factors: Short female urethra close to
vagina and anus Incomplete emptying bladder, they
have stasis: allows any bacteria that come from the urethra to grow
Stasis of reflux, when the child voids, urine backflows up the
Box 27-1Neonatal Period
(birth-1month): Poor feeding Vomiting Failure to gain weight Rapid respiration
(acidosis)
antibiotic therapy should be administered once pathogen is identified
Several antibiotics are specifically used to treat UTIs:
Penicillin’s Sulfonamide Cephalosporin
ureters and then flows back down into the empty bladder. It sits in the bladder and then bacteria from the urethra grow and the next time the child voids it happens again, except that now the urine that was in the bladder goes into the ureters, and can then go into the kidneys.
Over distention of bladder Concentrated urine Constipation E.coli 80% The key to prevention UTI is to
maintain adequate blood supply to the bladder wall by avoidance of over distention and higher bladder pressure
NURSING ALERT: a child who exhibits the following should be evaluated for UTI:
Incontinence in a toilet trained child
Strong smelling urine Frequency or urgency
NURSING TIP: Check the diaper every half hour. This increases the opportunity for observing the stream for such findings as straining or fretting before
Respiratory distress Spontaneous
pneumothorax or pneumomomediastinum
Frequent urination screaming on urination
Poor urine stream Jaundice Seizures Dehydration Enlarged kidneys or
bladderInfancy (1-24 months) Poor feeding Vomiting Failure to gain weight Excessive thirst Frequent urination Straining or screaming
on urination Foul-smelling urine Pallor Fever Persistent diaper rash Seizures (with or
without fever) Dehydration Enlarged kidney and
Nitrofurnatoion Surgical correction for primary
reflux or bladder neck obstruction
When a UTI is suspected collect a specimen (clean-voided specimen)
In infants and young children suprapubic aspiration of urine or sterile catheterization should be done in infants and young children who are seen with high fever
Increase fluid intake Children who have recurrent UTI
might be given low dose antibiotics, given at bedtime to allow the drug to remain in the bladder.
Prevention: Wipe front to back Avoid tight clothing or diapers;
wear cotton panties rather than nylon
Check for vaginitis and pinworms, especially if child scratches between legs.
Avoid holding urine; encourage child to void frequently,
voiding begins, signs of discomfort before and during urinating, starting and stopping the stream intermittently, and frequent dripping of small amounts of urine.
bladderChildhood (2-14
years) Poor appetite Vomiting Growth failure Excessive thirst Enuresis, incontinence,
frequent urination Painful urination Swelling face Seizures Pallor Fatigue Blood in urine Abdominal or back
pain Edema Hypertension Tetany (intermittent
muscle spasms)
especially before long trips or other circumstances in which toilet facilities are not available
Empty bladder completely with each void. Have the child “double void” (void wait a few minutes, and void again). Severe cases may require clean intermittent catheterization or biofeedback instruction
Avoid straining during defecation and constipation
Encourage generous fluid intake
Nephrotic Syndrome Characterized by increased glomerular permeability to plasma protein, which results in massive urinary protein loss.
Rare in children younger than 6 months
Uncommon infants younger than 1 year
Refer to chart below Edema Proteinuria Hypoalbuminemia Hypercholestolemia in
the absence of hematuria and HTN
Hallmark is massive
Refer to chart below
Complications: Rarely do children develop renal
failure with oliguria that significantly alters fluid and electrolyte imbalance resulting in hyperkalemia, acidosis,
Unusual after 8 years Most common between 2-7 years of
age A loss of protein reduces the serum
albumin level (hypoalbuminemia), decreasing colloidal osmotic pressure in the capillaries.
As a result the vascular hydrostatic pressure exceeds the pull of the colloidal osmotic pressure, causing fluid to accumulate in the interstitial spaces (edema) and body cavities, particularly in the abdominal cavity (ascites).
Shift of fluid from the plasma to the interstitial spaces reduces vascular fluid (hypovolemia), which in turn stimulates the renin-angiotensis system and the secretion of antidiuretic hormone and aldosterone
NURSING TIP: Another strategy for obtaining a daily urine protein is to place cotton balls in the diaper at night before bedtime and then squeeze them out in the morning
proteinuria (higher than 2+ on urine dipstick)
GFR is usually normal or high
Serum protein concentration is low
Serum albumin significantly reduced
Plasma lipids elevatedComplications: Circulatory
insufficiency secondary to hypervolemia and thermo-embolism
Infections that may be seen in children with NS include: peritonitis, cellulitis and pneumonia and require prompt recognition
hypocalcaemia, or hyperphosphatemia
Cerebral complications
Acute Glomerulonephritis
May be a primary event or manifested by a systemic disorder
Most cases are post-infection and
Refer back to question 1 above
Oliguria
Treated at home if: Urine output is ok BP is okay
have been associated with pneumococcal, streptococcal, and viral infection.
Can occur at any age Affects early school aged children
with peak age onset of 6-7 years Uncommon in children younger
than 2 years Can occur after a strep infection
with certain strains Immune complexes are deposited
in the glomerular basement membrane.
The glomeruli become edematous and infiltrated with polymorphonuclear leukocytes, which occlude capillary lumen
The resulting decrease in plasma filtration results in an excessive plasma and interstitial fluid volumes, leading to circulatory congestion and edema.
HTN due to fluid retention and renin production
Edema HTN Circulatory congestion Hematuria Proteinuria
Sometimes they only have a history of mild cold
Onset appears after an average of 10 days
Urinalysis of acute phase shows
Hematuria Proteinuria They usually both
parallel each other 3+ or 4 +
Gross discoloration of urine reflects RBC and hemoglobin content
Microscopic reveals many RBC, leukocytes, epithelial cells, and granular and RBC casts
Bacteria is not seen in urine
Treated in a hospital if: A lot of edema HTN Gross hematuria oliguria
Wilms Tumor nephroblastoma most common malignant renal and
intra-abdominal tumor of childhood
more commonly to occur in African Americans
peak age of dx is 3 years probably arises from malignant ,
undifferentiated cluster of primordial cells capable of intitiating the regeneration an abnormal structure
FAVORS the LEFT kidney. Test used for diagnosis: X-ray,
ultrasounds, CT, CAT scan, bone marrow biopsy
STAGES OF WILMS TUMOR Stage I: tumor is limited to kidney
and completely resected Stage II: tumor extends beyond
kidney but is completely resected Stage III: Residual non-
hematogenous tumor is confined to abdomen
Stage IV: heamatogenous metastases; deposits are beyond stage III, namely, to lung, liver, bone and brain
Stage V: bilateral renal
Abdominal swelling: Firm Non-tender Confined to one side
(L) Hematuria (less than
one fourth of cases) Fatigue and malaise HTN (occasionally) Weight loss Fever Manifestations
resulting from compression of tumor mass
Secondary metabolic alteration from tumor or metastasis
If metastasis symptoms of lung involvement:
Dyspnea Cough SOB Chest pain
Nursing Alert: To reinforce the need for cautions post a sign on the bed that reads: “DO NOT PALPATE ABDOMEN.” Careful bathing and handling are also important in preventing trauma to the tumor site
Once confirmed, surgery is scheduled ASAP 24-48 hours upon admission
As a nurse it is important to prep parents and children within this 24-28 hour period: simple, repetitive and focused (not much time)
BP is monitored because HTN from excess renin production is possible
Prep parents about chemotherapy side effects before surgery and children after; ie alopecia (hair loss)
Tumor affected kidney and adjacent adrenal gland are removed
A large trans-abdominal incision is performed
Great care is needed to keep the encapsulated tumor intact,
involvement is present at diagnosis because if ruptured it can spread to abdomen, lymph and bloodstream
Contralateral kidney is carefully inspected for evidence of disease or dysfunction
Regional lymph nodes are inspected
Biopsy performed when indicated
Any involved structures are removed
If both kidneys are involved, then radiotherapy or chemotherapy can be done before surgery to decrease the size of the tumor
May be possible to perform a partial nephrectomy on the opposite side
Bilateral nephrectomy is considered last resort if a transplant donor is available
The duration of therapy last 6-15 months
Post op care: Nurse must carefully monitor GI
activity, because the child is at risk for vincristine-induced ileus, radiation-induced edema, and
post surgical adhesion formation Bowel movement Bowel sounds Distention Vomiting Pain Nurse must also monitor BP Urinary output Signs of infections Institutes pulmonary hygiene to
prevent postop pulmonary complications
Radiotherapy indicated for children with large tumors
Chemotherapy for all stages The duration of therapy ranges
from 6-15 months Offer emotional support to
parents, the stage of the tumor is confirmed at this time
NURSING ALERT: Prompt detection and treatment of any genitourinary s/s are mandatory. Children with solitary kidney should be assessed and advised on the need for protective equipment before engaging in contact, collision or limited contact
activitiesAcute Renal Failure When kidneys are suddenly unable
to regulate the volume and composition or urine appropriately in response to food and fluid intake
The featured principal is oliguria, associated with azotemia, metabolic acidosis, and diverse electrolyte disturbances
Not common in childhood Usually reversible Severe reduction of GFR, an
elevated BUN level, and significant reduction in renal blood flow
Clinical course is variable and depends on cause
In reversible ARF, there is a period of severe oliguria, or a low-output phase, followed by an abrupt onset of diuresis, or a high-output phase, and then a gradual return (or toward) normal urine volumes
In many cases the infant or child is already critically ill with precipitating disorder, and the explanation for development of
Specific: Oliguria Anuria uncommon
(except in obstructive disorders)
Nonspecific (may develop): Nausea Vomiting Drowsiness Edema HTN
Manifestations of underlying disorder or pathologic condition
Complications: Hyperkalemia: No
extra K+ HTN: antihypertensive
drugs Anemia: transfusion
only recommended if hgb is below 6 g/dL
Seizures: antiepileptic
Monitor fluid balance Monitor vital signs 4-6 hours Observe for complications
continuously Blood transfusion is only
recommended if hgb drops below 6g/dL
May require dialysis Usually admitted to ICU, because
they require intensive care. Limiting fluid intake requires
ingenuity on the caregiver to cope with the child that is really thirsty
Rationing the daily fluid intake in small amounts of fluid served in containers that give the impression of larger volumes is one strategy.
Older children who understand the rationale of fluid limits can help determine how their daily ration should be.
When nourishment is provided via IV route, careful monitoring
oliguria may or may not be readily apparent
Diminished urinary output and lethargy in a child who is dehydrated, is in shock, or has recently undergone surgery should be evaluated for possible ARF
NURSING ALERT: Diminished urinary output and lethargy in a child who is dehydrated, is in shock, or has recently undergone surgery should be elevated for possible ARF.
NURSING ALERT: Any of the following signs of hyperkalemia constitute an emergency and are reported immediately”
Serum K+ concentrations in excess of 7 mEq/L
Presence of electrocardiographic abnormalities, such as prolonged QRS complex, depressed ST segment, high peaked T waves, bradycardia or heart block
drugs Cardiac failure: r/t
hypervolemia, tx by reducing fluid volume, with water and sodium restriction and administration of diuretics
QUALITY PATIENT OUTCOMES:
Underlying cause of ARF identified and treated
Water balance maintained
HTN controlled Electrolyte balance
maintained Diet maintains calories
while minimizing tissue catabolism, metabolic acidosis, hyperkalemia, and uremia
Significant lab
is important to prevent fluid overload.
Maintaining optimal thermal environment
Reducing any elevation of body temperature
Reducing restlessness and anxiety are used to decreased the rate of tissue catabolism
Children = anxious and frightened
Infants = restless and irritable If the child is able to tolerate
food, you want high carbohydrates, high fat, and low protein.
During oliguria phase = no sodium, chloride, or potassium, unless there are other larger, ongoing loses
Provide dietary that provides sufficient calories and protein
Limit phosphorous, salt and
measurements during renal shutdown that serve as a guide for therapy are BUN, serum creatinine, pH, sodium, potassium, and calcium.
potassium
Observe for evidence of accumulated waste products
Encourage intake of carbs and foods high in calcium
Nephrotic Syndrome Acute glomerulonephritisBox 27-2 pg 914
Weight gain Puffiness of face
(facial edema)
Box27-3 pg 915 Edema Especially
preorbital
Clinical Manifestation Especially around the eyes
Apparent on arising in the morning
Subside during the day
Abdominal swelling (ascites)
Pleural effusion Labial or scrotal
swelling Edema of intestinal
mucosa, possibly causing:
Diarrhea Anorexia Poor intestinal
absorption Ankle or leg swelling Irritability Easily fatigued Lethargic BP normal or slightly
decreased Susceptibility to
infection Urine alterations: Decreased volume Frothy (full of mass
around mucous)
Facial edema more prominent in the morning
Spreads during the day to involve extremities and abdomen
Anorexia Urine Cloudy, smoky
brown (resembles tea or cola)
Severely reduced volume
Pallor Irritability Lethargy Child appearing ill Child seldom
expresses specific complaints
Older children complaining of
Headaches Abdominal
discomfort Dysuria Vomiting possible Mild to severely
elevated blood
General Info: Nephrotic syndrome
is a clinical stat that includes massive proteinuria, hypoalbuminemia, hyperlipiidemia and edema
pressure
Nursing Management
Nutritional Therapy:
Low-salt diet Severe cases = fluid restriction Edema complications = diuretic
therapy initiated to provide temporary relief from edema
Due to severe protein loss = infusion 25% of albumin is used
Acute infections = tx with antibiotics
1st line of therapy = corticosteroids Starting dose for prednisone is
usually 2 mg/kg/day for 6 weeks; followed by 1.5 mg/kg every other day for 6 weeks Side effects: weight gain,
rounding of face, behavior changes, and appetite changes.
Moderate sodium restriction and fluid if child has HTN and edema
During periods of oliguria K+ is restricted
A record of daily weight is the most useful in for assessing fluid balance
Acute HTN is anticipated and identified early BP is taken 4-6 hours; HTN and diuretics are used
Long term: hirsutism, growth retardation, cataracts, HTN, gastrointestinal bleeding, bone demineralization, infection & hyperglycemia.
About 2/3 of children have a relapse
Monitor fluid retention and excretion (I&O) Collection bags (but it’s irritating
to skin) Applying diapers or weighing
wet pads may be necessary Place cotton balls in diaper at
night before bedtime and then squeeze them out in the morning)
Urine samples of albumin Daily weight Measurement of abdominal girth
(middle abdomen) Assessment of edema (ie,
increased or decreased swelling around the eyes and dependent areas); degree of pitting, and the color and texture of skin are part
Antibiotics used to treat children with evidence of strep infection, to help with spreading it to others
Note volume and character of urine
Children with fluid restriction, especially those with severe edema, or those who have lost weight are observed for signs of dehydration
Assessment of appearance for signs of cerebral complications
If a child has edema, HTN and gross hematuria they may be subject to complications; therefore, seizure
of nursing care Vital signs monitored to detect any
early signs of complications such as shock or an infective process
Because they are on corticosteroids they are at risk for infections (especially URI); therefore child must be kept warm and dry, active and protected from contact with infected individuals. Vital signs monitored to detect early signs
Appetite is lost, so the nurse with the help of others needs to formulate an attractive diet for child, with minimal salt during the edema phase, and while the child is on steroid therapy. You want to serve foods that the child likes, because remember you want them to eat!!!! Just don’t add salt (or very minimal
Fluid restriction is limited to short-term use during massive edema
Help them find activities that they
precautions and IV equipment should be included in care plan.
No added salt in diet If fluid restriction is
prescribed, the amount should be evenly divided throughout the waking hours
Activities should be planned to allow for frequent rest periods and avoidance of fatigue
Teach parents how to treat edema and how to care for child at home
Health supervision is continued throughout the week followed by monthly visits for urinalysis
like; steroids cause irritability and moods swings
Teach parents How to detect signs of relapse
and to call for changes of treatments
How to test the urine for albumin
Administer medication Provide general care Child needs to stay away from
infected individuals at school Unless, protein in urine is severe
or parents are not able to care for child, home health care is preferred
evaluation
Increased intercranial Pressure: Chapter 28
Chapter 28: Child with Cerebral Dysfunction 6 Questions
Clinical Manifestations of ICP (box 28-1)Infants:
Tense, bulging fontanel Separated cranial sutures-enlarged
head * Macewen (cracked-pot) sign Irritability and restlessness * Drowsiness Increased sleeping
High pitched cry * Increased frontoocipital
circumference Distended scalp veins * Poor feeding * Crying when disturbed Eyes: setting-sun sign *
Children: Headache * Nausea (sometimes) * Forceful vomiting * Diplopia, blurred vision * Seizures * Indifference, drowsiness
Decline in school performance Diminished physical activity and
motor performance Increased sleeping Inability to follow simple commands Lethargy
Late S/S in infants and children
Glasgow Coma Scale: Coma assessment that consists of 3-part assessment eye opening, verbal response and motor
response A score of 15 is the best –unaltered level of consciousness (LOC) A score of 3 is the worse score- extremely decrease LOC
Neuro Examination:Vital SignsSkinEyes:Doll Head Maneuver:
Rotate the child’s head quickly to one side and to the other. Normal response: eyes move in the opposite direction
Caloric test (aka oculovestibular test): Only do when child is unconscious Irrigate the external auditory canal with 10ml of ice water for 20 seconds Elicited with child’s head up (HOB 30 degrees) Normal response: movement of eyes toward the side of stimulation
NURSING ALERT(S) The sudden appearance of a fixed and dilated pupil(s) is a neurologic emergency Any tests that require head movement are not attempted until after cervical spine injury has
been ruled out The caloric test is painful and is never performed on a child who is awake or on an individual
with a ruptured tympanic membrane
Motor FunctionPosturing:
Flexion Extension
Reflexes:NURSING ALERT
3 key reflexes that demonstrate neurologic health in young infants are the: Moro, tonic neck and withdrawal reflexes
Procedures: Lumbar puncture is contraindicated when there is a suspicion of ICP
Nursing Care of the Unconscious Child Emergency measures are directed toward ensuring
o Patent airway (breathing) and circulationo Treating shock (stabilizing the spine)o Reduce ICP
Continual observation of LOCDRUG ALERT: When opioids are used, bowel elimination must be closely monitored because of the
potential constipating effect. Stool softeners should be given with laxatives as needed to prevent constipation
NURSING ALERTo Respiratory obstruction and subsequent compromise leads to cardiac arrest.
Maintaining an adequate, patent airway is of the utmost importance NURSING ALERT:
o The HOB is elevated to 30 degrees, and the child is positioned, so that the head is maintained in midline to facilitate venous drainage and avoid jugular compression. Turning side to side is contraindicated because of the risk of jugular compression.
Hypoxia and the Valsalva maneuver can increase ICP Suctioning in contraindicated, unless it is necessary; Make sure it is brief and preceded by
hyperventilation with 100% O2. If suctioning, oxygenate prior to suctioning. Suctioning should be brief. Increase in intrathoracic abdominal pressure will be transmitted to the cranium. Avoid neck vein compression
Make sure to watch for overhydration, it can cause cerebral edema Antipyretic agents are usually not effective, therefore external cooling should be used,
which consists of evaporation (sponge baths), conduction (ice packs, cooling blankets), convection (fans), and radiation (skin exposure)
Mouth care is performed at least 2X a day, because the mouth tends to get dry coated with mucus. Clean teeth with soft toothbrush or clean with gauze-saturated saline. Chap stick for lip (make sure it is not an oil based product.
NURSING ALERT:o The eyes should be examined regularly and carefully for early signs of irritation or
inflammation. Artificial tears or a lubricating ointment is placed in the eyes every 1-2 hours. Eye dressings may be necessary to protect the eyes from possible damage
HEAD INJURY: 3 major causes: Falls, Motor Vehicle Injuries and Bicycle or sports related injuries Contrecoup = know that a child can have injury on the opposite side of injury
Clinical Manifestations (BOX 28-3)
Minor Injury: May or may not lose
consciousness Transient period of
confusion Somnolence
Listlessness Irritability Pallor Vomiting (one or more
episodesSigns of progression:
Altered mental status (difficulty arousing child)
Mounting agitation
Development of focal lateral neurologic signs
Marked changes in vital signsSever Injury:
Signs of increased intracranial pressure (box 28-1)
Bulging fontanel (infant) Retinal hemorrhages Extraocular palsies
(especially CNIII)
Hemiparesis Quadriplegia Elevated temperature Unsteady gait papilledema
Associated Signs Scalp trauma Other injuries (to extremities)
Major complications of Heady Injury Hemorrhage Infection Cerebral Edema Herniation Bradycardia Decreased motor response to command Decreased sensory response to painful stimuli Alterations in pupil size and reactivity Extension or flexion posturing Cheyne-Strokes respiration Papilledema Decreased consciousness Comma
NURSING ALERT (S) Posttraumatic meningitis should be suspected in children with increasing drowsiness and
fever who also have basilar skull fractures Children with subdural hematoma and retina hemorrhages should be evaluated for the
possibility of child abuse, especially shaken baby syndrome Stabilize a child’s spine after head injury until spinal cord injury is ruled out Deep, rapid, periodic or intermittent and gasping respirations; wide fluctuations or
noticeable slowing of the pulse: and widening pulse pressure or extreme fluctuations in BP are signs of brainstem involvement.. Note that the marked hypotension may represent internal injuries
Observation of asymmetric pupils or one dilated, nonreactive pupil in a comatose child is a neurologic emergency
Bleeding from the nose or ears needs further evaluation, and watery discharge from the nose (rhinorrhea) that is positive for glucose (as tested with Dextrostix) suggest leaking of CSF from skull fracture
Nursing Considerations/Treatment NPO or restricted to clear liquids, until vomiting does not occur IV fluids for comatose child, or continuously vomiting Daily weight I&Os Serum osmolality to detect early s/s of: H2O retention, excessive dehydration, and states of
hypertonicity or hypotonicity Neurological assessment, most important is LOC assessment; try to have by one single
observer, so they can notice any slow changes Safety Measures: side rails up, seizure precautions Provide a quiet environment Provide sedation and analgesic for child Report any seizure
Document drainage of any orifice Suture for lacerations Antiepileptic for seizures Antibiotics if lacerations or CSF leakage
NURSING ALERT: Suctioning through the nares is contraindicated because of the risk if the catheter entering
the brain parenchyma through a fracture in the skullTeaching
Check child every 2 hours, if child is asleep wake them up s/s of increased ICP no narcotics or pain medication, report HCP Vomiting could be a sign of ICP, contact HCP
Bacterial MeningitisPrevention:
Immunization of Hib Nursing Consideration:
Keep room quiet Keep environmental stimuli to a minimum HOB slightly elevated Side lying positioning Evaluate for pain (acetaminophen with codeine); Careful to evaluate patient for a fever
before administration, because this can the fever go away and a fever is an indicator of infection
Vital signs Promote adequate fluid and nutritional status Observation of VS, neurological signs, LOC, I&Os Frequent assessment of open fontanels Maintaining IV infusion for antibiotic therapy Isolation Precautions
NURSING ALERT: A major priority of care of a child suspected of having meningitis is to administer
antibiotics ASAP. The child is placed on respiratory isolation for at least 24 hours after initiation of antimicrobial medication
Endocrine System: Chapter 29 (5 questions)
Type 1: destruction of pancreatic beta cells, which produce insulin; this usually leads to absolute insulin deficiency.
o Abrupt onseto <20 yearso 3Ps: polyuria, polydipsia, polyphagia and underweight; others: blurred vision and
fatigue Type 2: usually arises because of insulin resistance in which the body fails to use insulin
properly combined with relative (rather than absolute) insulin deficiencyo Gradual onseto Adults, but increasing in childreno Presenting symptoms may be r/t long term complications, overweight
Nursing Considerations/Treatment Type 1 replacement of insulin that the child can not produce Types of insulin:
o Rapid acting: (Novolog, Lispiro) Onset 15 minutes Peak 30-90 min Duration
o Short aciting (Novolin R.) Onset 30 min Peak 2-4 hours Duration Administer 30 mintues before meals
o Intermediate-acting (Novolin NPH) Onset 2-6 hours Peak 4-14 hours Duration 14-20 hours
o Long-acting (Lantus) Onset 6-14 hours Peak 10-16 hours (no peak) Duration All day
Nursing Consideration/Treatment:NURSING ALERT:
Hypoglycemic episodes most commonly occur before meals or when the insulin effect is peaking
Hypoglycemic s/s: pallor, tremulosness, palpations, , sweating, hunger, weakness, dizziness, headache….etc REMEMBER cold and clamy give some candy
o Give a 10-15 g simple carb (1 TBS of sugar) , followed by a complex carb and a protein (slice of bread or cracker and protein such as PB or milk
Glucagon functions by releasing stored glycogen from the liver and requires about 15-20 minutes to elevate the blood glucose levels
oTeaching
Timing of food consumption must be regulated to correspond to the timing and action of the insulin prescribed
Extra food is needed for increased activity Concentrated sweets are discouraged Fat is recommended to be reduced to 30% or less of total caloric requirement Intake of dietary fiber Exercise lowers blood glucose levels, if exercised is unplanned one can compensate by
providing extra snack. If person is exercising consistently then insulin can be reduced
Integumentary System: Chapter 30 (3 questions)
Relief of pruiurits by cooling the affected area and increasing the skin pH with cool baths or compresses and alkaline applications (baking soda baths)
Clothing and bed linen should be soft and lightweight to decrease the irritant from friction and stimulation
Keeping fingernails short and trimmed reduce the risk for secondary infections Antipyretic medications can be prescribed for sever itching, especially if it disrupts rest
NURSING ALERTS Application of heat tends to aggravate most conditions and its use is usually reserved for
reducing inflammatory process, such as folliculitis and cellulitis Signs of wound infections are
o Increased erythema, especially beyond the would margin
o Edema
o Purulent exudateo Paino Increased temperature
Do not put anything in a wound that you would not put in an eye. The safest solution is normal saline
Advise parents that the yellow gel forming under hydrocolloid dressings may look like pus and has a distinct odor (somewhat fruity) but is normal leakage
Provide written instructions and demonstrate to parent the correct amount of topical medication to apply. If more than one prescription is applied, mark the containers with numbers so the parents remember the correct order of application. Stress that more is not necessarily better with some medications such as steroids
IV drugs are more likely to cause a reaction than oral drugs, Stop the drug but maintain the infusion with normal saline
Neuroskeletal System: Chapter 31 (2 questions)
Immobilization: Inactivity leads to a decrease in the functional capabilities of the whole body as dramatically
as the lack of physical exercise leads to muscle weakness Most of the pathological changes that occur during immobilization arise from decreased
muscle strength and mass, decreased metabolism, and bone demineralizations The daily stress on bone created by motion and weight bearing maintain the balance
between bone formation and reabsorptionNursing Care/ treatment
Systems that can be affected secondarily circulatory, respiratory, renal, muscular, GI systems With long-term immobilization there may be neurological impairment, and changes in
electrolytes (especially calcium), nitrogen balance, and the general metabolic rate Prevent skin breakdown placed on a pressure-reduction mattress to prevent skin
breakdown, Can use the Braden Q scale in the assessment for pressure ulcer development for children at
risk for kin breakdown Antiembolism stockings or intermittent compression devices Anticoagulant therapy Diet: high protein, high caloric foods are encourage to prevent negative nitrogen balance if
there is anorexia due to decrease in GI mobility Nasogastric or gastrostomy feedings or IV fluids may be needed to maintain nutrition When possible upright position Have child associate with others by increasing environmental stimuli and allowing social
contact with others Use dolls or stuffed animals to illustrate and explain immobilization methods Have them participate in their own care
Growth Plate (Physeal) Injuries It is the weakest point of the cartilage; therefore it is a frequent site of damage during
trauma. It is important because it may affect future bone growth. Clinical Manifestation (BOX 31-2)Signs of injury:
Generalized swelling Pain or tenderness Deformity
Diminished functional use of affected limb or digit
May also demonstrate: Bruising Severe muscular` rigidity
Crepitus (grating sensation at a fracture site)
NURSING ALERT A fracture should be strongly suspected in a small child who refuses to walk or crawl
Nursing Consideration/Treatment Goal:
o To regain alignment and length of the bony fractures (reduction)o To retain alignment and length (immobilization)o To restore function to the injured partso To prevent further injury and deformity
Fractures are splinted or casted to immobilize and protect the injured extremity EMERGENCY TREATMENT (pg. 1059):
o Determine the mechanism of injuryo Assess the 6Ps
o Move the injured part as little as possible o Cover open wounds with sterile or clean dressingo Immobilize the limb, including joints above and below the fracture site; do not
attempt to reduce the fracture or push protruding bone under the skin.o Use a soft splint (pillow or folded towel) or rigid splint (rolled newspaper or
magazine)o Uninjured leg can serve as a splint for leg fracture if no splint is availableo Reassess neurovascular statuso Apply traction if circulatory compromise is presento Elevate the injured limb if possibleo Apply cold to the injured areao Call emergency medical services or transport to medical facility
NURSING ALERT: Compartment syndrome is a serious complication that results from compression of nerves,
blood vessels, and muscle inside a closed space. The injury may be devastating, resulting in tissue death, and this requires emergency treatment (fasciotomy). The 6Ps of ischemia from a vascular, soft tissue, nerve, or bone injury should be included in an assessment of any injury:
o Paino Pulselessnesso Palloro Paresthesia o Paralysiso Pressure
The Child in a CastCast Application:
Consider the child’s developmental stage before o Preschool: use a plastic doll or stuffed animal to explain procedureo Let them know what to expect: like that it will get warm during applicationo Use distracting methods: like blowing bubbles, asking them questions that focus on
them etc Turn child every 2 hours to help dry body cast evenly Support a plaster cast with a pillow, and handle with palms of hands Hot spots felt or foul smelling odor can indicate infection
NURSING ALERTS: Heated fans or dryers are not used because they cause the cast to dry on the outside and
remain wet beneath or cause burns from heat conduction by way of the cast to the underlying tissue
Observations such as pain (unrelieved by pain medication 1 hour after administration, especially with passive ROM), swelling, discoloration (pallor, cyanosis) of the exposed portions, decreased temperature, paresthesia, or the inability to move the distal exposed part(s) should be reported ASAP. Pallor, paralysis, and pulselessness are late signs.
LOOK at Family Centered Care-Cast Care PG 1061 Feeding a child in a hip-spica cast supine with head elevated; Children in spica cast usually find prone position easier for self feeding
Cast Removal Explain what the child should expect, tickling sensation and heat may be felt. Reassurance that it will be okay, let them keep cast at the end (if they want to) Teach them that they can use mineral oil or lotion to remove particles left behind.
evelopmental Dysplasia of the Hip: A spectrum of disorders related to abnormal development of the hip that may occur at any
time during fetal life, infancy or childhood. Diagnostic Testing’s (LOOK at pg 1069):
Ortonali o Involves abducting the thighs to test for hip subluxation or dislocationo With clunk elicited (infants < 4 weeks)o Positive test hip reduced by abduction
Barlow Test o Thighs are adductedo Positive test hip is dislocated by adduction
Clinical Manifestations:Infants
Asymmetry of gluteal and thigh folds Limited abduction (as seen in flexion) Apparent shortening of the femur
(level of knee flexion)
Shortening of the limb on the affected side
Broadening of the perineum (in a bilateral dislocation)
Decreased hip abductionOlder Infants:
Affected leg appears shorter than the other Telescoping or piston mobility of joint-head femur felt to move up and down in buttock
when extended thigh is pushed first toward child’s head and then pulled distally Trendelenburg sign-When child stands first on one foot and then on the other (holding
onto a chair, rail) bearing weight on affected hip, pelvis tilts downward on normal side instead of upward, as it would with normal stability
Greater trochanter prominent and appearing above a line from anterosuperior iliac spine to tuberosity of ischium
Marked lordosis and waddling gait (bilateral hip dislocation)Nursing Consideration/Treatment
Major problem is the maintenance of the device and adaptations with child and/parentNB-6months
Pavlik Harness, o Hip in an abducted, reduced positiono Worn continuously until the hip is proved stable on clinical and ultrasound
examination, usually for 6-12 weekso Since infants grow rapidly, the straps should be checked weekly for adjustments
(parent’s are not allowed to adjust it)o Removing depends on the provider’s recommendation, which will be based on the
deformity and family level of understandingo Skin care to prevent breakdown are very IMPORTANT
Always put on undershirts (or a shirt with extension that close at the crotch) under the chest straps and put knee socks under the foot pieces to prevent the straps from subbing the skin
Check frequently (at least 2-3X a day) for red areas under the straps and the clothing
Gentle massage healthy skin under the straps once a day to stimulate circulation, In general avoid lotions and powders, because they can cake and irritate the skin
Always place the diaper under the straps Other devices are used for adduction contracture is present
When there is difficulty maintain stable reduction, a hip spica cast is used and changed periodical to accommodate the child’s growth.
Duration of treatment on the development of the acetabulum, but is usually accomplished within the 1st year
6-24 months Surgical closed reduction is performed Spica cast for almost 12 weeks OR a abduction orthosis may be used Open reduction is performed if hip remains unstable
Older Children More difficult to accomplish in this age group, the older the child gets the harder it is to
reconstruct Requires several procedures, and complete reconstruct
NURSING ALERT: The former practice of double or triple diapering for DDH is not recommended because
there is no evidence to support its efficacy.
Clubfoot A complex deformity of the ankle and foot that includes forefoot adduction, midfoot
supination, hindfoot varus, and ankle equinusNursing Consideration/Treatment
Goal is to achieve: painless, plantigrade, & stable foot Ponseti method; Serial casting is stared right after birth Weekly gentle manipulation and serial long-leg cast allow for gradual repositioning of the
foot. Extremities are casted until maximum correction is achieved can take 6-10 weeks Then tenotomy is performed Then long-leg cast is performed and left for 3 weeks Ponseti sandals or straight-laced shoes placed in abduction are then fitted to prevent
recurrence Inability to achieve normal foot alignment after casting and tenotomy indicates the need for
surgical intervention
Parent Teaching: Understand the importance of regular cast changes, and the role they play in the long-term
effectiveness of the therapy Teach parent care of the cast appliances
Osteogenesis Imperfecta Osteoporosis syndrome in children Heterogeneous inherited disorder of connective tissue Defective periosteal bone formation and reduced cortical thickness of bones
Nursing Consideration/Treatment Primarly supportive Bisphiosphonate therapy with IV pamidronate to promote increased bone density and
prevent fractures has become standard therapy for many children (however, long bones are weekend by prolonged treatment
Lightweight braces and splints help support limbs, prevent fractures and help to get around Physical therapy Surgery to treat manifestations
Parent Teaching Require careful handling to prevent fractures: supported when being turned, positioned,
moved, held. Never hold by the ankles when diapered, instead lift by the buttocks or support with pillow
Education regarding child’s limitation, and suitable activities Occupational planning Genetic counseling
NURSING ALERT: Children with multiple fractures should be screened for OI. The possibility that non-
accidental trauma is the cause of the fracture in children must be carefully elevated by a multidisciplinary team
Slipped Capital Femoral Epiphysis Spontaneous displacement of the proximal femoral epiphysis in a posterior and inferior
direction Develops before or during accelerated growth (puberty)
Clinical Manifestation (BOX 31-8) Very often obese (body mass index >95%) Limp on affected side Possible inability to bear weight because of sever pain Pain in groin, thigh or knee
o May be acute, chronic or acute-on-chronico Continuous or intermittent
Affected leg is externally rotated Loss of abduction and internal rotation as severity increases Shortening of lower extremity
Nursing Consideration Non-weight bearing to prevent further slippage Surgery within 24 hours of dx (depends on the surgeon Surgical pinning in situ involves the placement of a single pin or multiple pin s and scres
through the femoral neck osteotomy for deformity Hip arthroscopy before situ pinning in shown to decrease pain and allow early hip
movement Postsurgical care includes NON-WEIGHT bearing with CRUTCH AMBULATION until painless
ROM Postop care involves hemodynamic stabilization and assessment for complication
NURSING ALERT: Children with hip issues such as Legg-Calve-Perthes or SCFE often present with groin, thigh
or knee pain. This is often because of referred pain and is anatomically related to the obturator nerve. Any time a child presents with groin, thigh, or knee pain a complete hip examination is paramount to rule out underlying hip pathology
Osteomyelitis Infectious process in the bone tissue Can be caused by hematogenous sources and exogenous sources
Clinical Manifestations General
o Possible history of trauma to affected bone
o Child appears very illo Irritability
o Restlessnesso Elevated Temperatureo Rapid Pulseo Dehydration
o Local
o Tendernesso Increased warmtho Diffuse swelling over
involved boneo Involved extremity painful,
especially on movement
o Involved extremity held in semi flexion
o Surrounding muscles tens and resistant to passive movement
Nursing Consideration/Treatment Collect culture Start empiric antibiotics When the infectious agent is identified, continue antibiotic treatment for 3-4 weeks (6 wks-4
months sometimes) Monitor hematologic, renal, hepatic, ototoxic side effects To prevent antibiotics-associated diarrhea in some children, administer a probiotic Position comfortably with affected limb supported Temporary splint or cast may be applied Avoid weight-bearing in the acute phase Child may require long-term pain medication to deal with bone pain Carful observation of IV equipment and site (PICC line can be inserted for long term
antibiotics) Implement standard precautions: wound care to prevent infection Provide child with activities for those confined to bed for some time during the acute phase,
but may be allowed to move on a stretcher or wheelchair if isolation is not necessary. Mainly the child will have complete bed rest and immobility of limb
Juvenile Idiopathic Arthritis (Juvenile Rheumatoid Arthritis) A chronic autoimmune inflammatory disease causing inflammation of joints and other tissue
with an unknown cause Chronic inflammation of the synovium with joint effusion and eventual erosion, destruction,
and fibrosis of the articular cartilage Chronic and acute uveitis can cause permanent vision loss if undiagnosed and not
aggressively treated; Uveitis is unique to JIA
Clinical Manifestations Arthritis tends to wax and wane
(increase and then decrease); s/s increase with stressors
Joint deformity Functional disability Stiffness Swelling Loss of mobility in affected joints Warm to touch, usually erythema Tender to touch in some cases Growth retardation
Nursing Consideration/Treatment GOAL: control pain, preserve joint ROM, minimize effects of inflammation such as joint
deformity and promote normal growth and development Drugs therapy (opioid analgesics are usually avoided):
o NSAIDs Teach parent not to give on an empty stomach
o Methotrexate (in combination with NSAIDs) Monitor CBC and liver function Patient education on birth defects Teach teens to avoid alcohol
o Corticosteroids PO, IV, eye drop for UVEITIS Teach about long term effects: Cushing syndrome, osteoporosis, increased
infection risk, glucose intolerance, cataracts and growth suppressiono Biologic agents
Teach about Side effects: increased risk for infection, rare reports about demyelinating disease and pancytopenia, and allergic reaction
Because of the infection risk, evaluate child for TB exposure Physical and Occupational Therapy Caloric intake needs to match energy needs to avoid weight gain, if child is inactive Sleep and rest Firm mattress , electric blanket, or sleeping bag helps provide warmth, comfort and rest Nighttime splints to help maintain ROM (splint should not be painful or impede sleep) Well-child care to assess growth, development, and immunization requirements needs to be
coordinated between the primary care provider and rheumatologist Seek medical attention ASAP for other illnesses (like URI) to prevent arthritis flare ups School nurse should be aware, and notified of child’s condition (child needs to take
medication and, come in to rest if needed) A formal school hearing may be necessary to obtain an Individualized Education Program,
ensured by public law, which includes intensive school modifications Moist heat is best for relieving pain and stiffness Bathtub with warm water Also daily whirlpool bath, paraffin bath or hotpacks prn for acute swelling and pain hotpacks applied using a bath towel wrung out after being immersed in hot water or headed
in a microwave oven-apply to area and cover with plastic for 20 minutes painful hands or feet can be immersed in a pan of warm water for 10 minutes 2-3 X daily pool therapy best and easiest for exercise You want the child to perform ADLs on their own ; therefore, advise to use helpful devices,
self-adhering fasteners, tongs for manipulating difficult objects, grab bars installed in bathrooms for safety, and raised (higher) toilet seat
Parent Teaching Begin the day by waking up the child early, administering medication and then letting
them sleep for an hour Take a hot bath (or shower) Perform a simple ritual of limbering-up-exercise Exercise, heat and rest are spaced throughout the day
Neuromuscular System: Chapter 32 (4 questions)
Cerebral Palsy: Group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive
disturbances that occurred in the developing fetal or infant brain Other medical disorders associated: mental impairment, seizures or epilepsy, growth problems, impaired vision or hearing and abnormal
sensation or perception Many develop the condion during prenatal development or childbirth, very few afterwards
Nursing Considerations/Treatment Supportive Since jaw control in often compromised, more normal control can be achieved if the feeder provides stability of the oral mechanism
from the side or front of face Safety precautions are implemented, such as having child wear protective helmets if they are subject to falls or capable of injuring their heads
on hard objects Home and environment should be adapted to their need to prevent bodily harm Administer appropriate immunizations to prevent childhood illnesses and protect against respiratory infection: influenza, pneumonia Dental problems, dental care is very important Federally approved safety restraint should be used at all times in cars, and recommended for them to ride in the back of car in a rear facing
position Physical, speech and occupational therapy Use devices that will help with ADLs, and make sure the patient does as much as possible. Since they might get tired offer frequent rest periods. Nursing Alert:
Mobile infant walkers are discouraged in children with CP. They pose a risk for injury
Spina Bifida: Midline defects involving failure to the osseous (bony) spine to close Can be prevented if the mother takes folic acid (should be taken by all females of who are capable of getting pregnant
Nursing Consideration/Treatment Assess infant for level of neurological involvement Movement of extremities or skin response, especially an anal reflex that might provide clues to the degree of motor or sensory impairment Observation of urinary output Abdominal distention revealing bladder distention The head circumference is measured daily and the fontanels are examined for sings of tension or bilging Infant is placed in an incubator or warmer so temperature can be maintained without clothing or covers that might irritate the spinal lesion
When an overhead warmer is use, dressings over defect requires more moistening, because of the dehydrating effects of radiation heat Sterile normal saline, moist, nonadherent dressing over defect Sac must be carefully cleansed if it becomes soiled or contaminated Positioning the child is important; the child must be kept in the prone position to minimize tension on the sac and the risk for trauma; prone
with hips slightly flexed and supported to reduce tension on the defect. Put a pad between the knees to counteract hip subluxation Turn infants head for feedings Prone position is maintained after surgical closure, although many neurosurgeons allow a side-lying or partial side lying position Children with SB are at high risk for developing latex allergies, because of repeated exposure to latex products during surgery and procedures-
need a latex free enviornment
NURSING ALERT:Observe for early signs of infection, such as temperature instability (axillary), irritability, and lethargy, and for signs of increased intracranial pressure , which might indicate developing hydrocephalus .
Duchenne Muscular Dystrophy Most severe and most common muscular dysfunction in childhood Inherited as an X-linked recessive trait and the single-gene defect High mutation rate with a positive family history in 65% Genetic counseling Early onset, usually between 3-7 years of age Progressive muscular weakness, wasting and contractures Calf muscle hypertrophy in most patients Loss of independent ambulation by 6-12 years of age Slowly progressive, generalized weakness during teenage years.
Clinical Manifestations: Relentless progression of muscle weakness, possible death from respiratory or cardiac failure Waddling gait Lordosis Frequent falls Gower sign: child turns onto side or abdomen; flexes knees to assume a kneeling potions; and then with knees extended, gradually pushes
torso to an upright position by “walking” the hands up the legs Enlarged muscles especially calves, thighs and upper arms; feel usually firm or woody on palpation Later stage: profound muscular atrophy Mental deficiency Complications:
o Contracture deformities of hips, knees, and ankles
o Disuse atrophyo Cardiomyopathyo Obesity and at times under nutritiono Respiratory compromise and cardiac failure
EXAM 4 child ?drink milk if shaky, dizzychicken leg—SIADH lay supine after a shuntcandida albicans—anal lesions and redness. inflamed joints—leg calvedon’t give Aspirin to varicella/chickenpox childDDH select all that apply 3 answersosteogenesis imperfect—homeschool child to prevent injurySeizure meds-dont abruptly stop