Chapter 31- Care of Child with a Physical Disorder

Jessica Gonzales RN, MSN

Cardiovascular assessment

clubbing

Periorbital edema

Monitor BP for hypo or hypertension

Monitor apical and peripheralPulses for rate, rhythm, and qualityAuscultate for extra heart sounds

Monitor respirations for rate and effortAusculate for adventitious sounds

Assess heightAnd weight, Growth failure Can occur with Sever cardiac disease

Peripheral edema• Palpate• inspect

cyanosis

EngorgedNeck veins

Abdominal distensionPalpate forHepatomegalyAndsplenogmegaly

Congenital Heart Disease

Etiology and pathophysiology:♥ Family history of CHD♥ Mom comes in contact with certain substances during first

few weeks of pregnancy♥ Mom with seizure disorder and on meds♥ Depression and lithium♥ Uncontrolled diabetes or lupus♥ Rubella♥ Chromosomal abnormalities (downs syndrome, turners)♥ infection

1. Inferior and superior vena cava from body into right atrium2. Right atrium to right ventricle via tricuspid valve3. Through pulmonary valve to pulmonary artery4. Pulmonary artery to lungs5. To pulmonary veins from lungs

6.Pulmonary veins to left atrium7.Through mitral valve into left ventricle8.Through aortic valve to aorta9. To body

Tissue Paper My AssestsR u i oI l t rC m r tU o a iS n l cP i I cD

Left ventricle

Left atrium

tricuspid

Superior vena cava

Inferior vena cava

pulmonicaortic

mitralRightatrium

Right ventricle

• Types of defects:

♥ Pulmonary Blood flow

♥ Pulmonary Blood Flow

♥ Obstruction to systemic blood flow♥ Mixed blood flow ♥ Cyanotic♥ Acyonotic

Cyanotic Acyanotic Pulmonary Blood flow

♥TGA

Pulmonary Blood flow♥VSD♥PDA♥ASD

Pulmonary Blood flow

♥TOF

Normal Blood Flow♥COA

R L

LR

Cyanotic

Acyanotic

4 T’s• Tetralogy of fallot• Truncus Ateriosus• Transportation of the great vessels• Tricuspid Atresia

• PDA• ASD• VSD

Clinical manifestations• Cyanosis • pallor• Cardiomegaly, • additional heart sounds (pericardial rubs, murmurs,) • Discrepancies between apical and radial pulses• Tachypnea• Dyspnea, grunting, crackles, and wheezes• Digital clubbing • Hepatomegaly, splenomegaly

Acyanotic

https://health.google.com/health/ref/Patent+ductus+arteriosus

Patent ductus arteriosus (PDA) is a condition in which a blood vessel called the ductus arteriosus fails to close normally in an infant soon after birth. (The word "patent" means open.)

IncreasedPulmonary Blood flow

AcyanoticIncreased pulmonary blood flow

Atrial septal defect (ASD) is a congenital heart defect in which the wall that separates the upper heart chambers (atria) does not close completely. Congenital means the defect is present at birth.

Ventricular septal defect (VSD)describes one or more holes in the wall that separates the right and left ventricles of the heart. Ventricular septal defect is one of the most common congenital (present from birth) heart defects. It may occur by itself or with other congenital diseases.

acyanotic Increased pulmonary blood flow

Opening between ventricles

A large ventricular septal defect (VSD): a hole in the part of the septum that separates the ventricles, the lower chambers of the heart. The hole allows oxygen-rich blood from the left ventricle to mix with oxygen-poor blood from the right ventricle.

Pulmonary stenosis

Pulmonary stenosis : This defect is a narrowing of the pulmonary valve and the passage through which blood flows from the right ventricle to the pulmonary artery. In pulmonary stenosis, the heart has to work harder than normal to pump blood, and not

enough blood reaches the lungs.

Right ventricular hypertrophy

Right ventricular hypertrophy : This defect occurs if the right ventricle thickens because the heart has to pump harder than it should to move blood through the narrowed pulmonary valve.

Overriding aorta

An overriding aorta: the aorta is between the left and right ventricles, directly over the VSD. As a result, oxygen-poor blood from the right ventricle flows directly

cyanotic

Decreased Pulmonary Blood flow

Children with TOF may develop "tet spells“ (acute hypoxia)

• The precise mechanism of these episodes is in doubt

• presumably results from a transient In resistance to blood flow to the lungs with flow of desaturated blood to the body

• characterized by a sudden, marked, increase in cyanosis followed by syncope, and may result in hypoxic brain injury and death, prolonged crying, irritability

treatment:• Calm infant- hold over shoulder or in knee chest position or have child

squat (increases pressure on the left side of the heart, decreaseing the R to L shunt thus decreasing the amount of deoxygenated blood entering systemic circulation)

• Morphine (to decrease spasm and supress resp center)

• Oxygen (it is a potent pulmonary vasodilator and systemic vasoconstrictor. This allows more blood flow to the lungs)

• Consider sedation and parlaysis with intubation if these measures fail

Transposition of the great vessels is a congenital heart defect in which the two major vessels that carry blood away from the heart -- the aorta and the pulmonary artery -- are switched (transposed).

cyanotic Increased Pulmonary blood flow

Aortic coarctation is a narrowing of part of the aorta (the major artery leading out of the heart). It is a type of birth defect. Coarctation means narrowing

Acyanotic Normal pulmonary blood flow

Hematological assessment

Pallor,flushingJaundice,Purpura,Petichiae,Scratch markscyanosis

Jaundice, sclera, retinal hemorrhage

TachycardiaAuscultate for murmurs

Tachypnea, orthopnea, dyspnea

Impaired thoughtProcess or lethargy

Palpate decreased cap fill time

Joint swelling,Bone and joint tenderness

Blood in urine and abnormal Mentsraulbleeding

Gingival pallor or bleeding

Lymphadenopathy or tenderness

Abdominal tenderness,Hepatomegaly,splenomegaly

Decreased muscle mass

Disorders of Hematological Function

• Anemia: The condition of having less than the normal number of red blood cells or less than the normal quantity of hemoglobin in the blood. The oxygen-carrying capacity of the blood is, therefore, decreased

Failure to produce (hem)oglobin due to

lack of iron

Iron containing O2 transport protein

that carries O2 from the lungs to

the body

Iron needed to bind

O2

Reduces O2 carrying

capacity of the blood

O2 state to the tissues: dyspnea on exertion, fatique,

fainting, lightheadedness, tinnitus, headache

In anemia selective vasoconstriction of

blood vessels allows nonvital

areas to be bypassed to allow

more blood to flow into critical areas. The skin is one of

the areas to be considered

“nonvital” and the result is pallor.

Tissue hypoxia= ↑cardiac input= ↓PVR & ↓blood viscosity (thinner

blood) = tachycardia and heart murmur

A genetic disorder characterized by an abnormal form of hemoglobin within the

erythrocyte

Ischemia in the small blood vessels and infarction in the

small bones

Ischemia in the small blood vessels and infarction in

the small bones

↓ O2 = sickle shaped red blood cells break apart

not acting effectively

Damaged sickle RBC’s clump

together and stick to the walls of blood vessels, blocking

blood flow causing sever pain and

permanent damage to brain, heart,

lungs, kidneys, liver, bones, and spleen

↑Risk of infection due to damaged spleen from sickled

cells getting trapped

Aplastic Anemia is a rare but potentially life threatening syndrome of bone marrow failure characterized by pancytopenia

↓RBC’s fatigue due to ↓O2

infections

Bruising and bleeding

Failure to produce hemoglobin due to

lack of iron

• Iron replacement therapy

• Nutritional or dietary counseling

• Treatment of underlying cause

• Infection• Pain

• Fatigue • Shortness if

breath

broad spectrum antibiotics

Pain medications, local heat application

** hydration to prevent sickling

• Pallor• Dyspnea• Petechiae• bleeding

• Fever• Infection

Administer O2, semi-fowlers postion

Good oral hygiene, patient safety

Prophylactic antibiotics

• Transfusions as needed• Isolation precautions per institute (reverse isolation)

platelets bleeding

• Prevent bruising• Control bleeding

• Counsel family to not use salicylate drugs• Transfusion of RBC’s

• IV gamma globulin and anti-D antibody therapy• splenectomy

Idiopathic thrombocytopenic purpura (bleeding

in the tissue)

A bleeding disorder

in which the immune system

destroys platelets, which are necessary

for normal blood clotting.

Persons with the disease have too few platelets in

the blood*antiplatelet

antibody in the spleen

Hemophillia• Hereditary (x-linked recessive transmitted by females found predominately in

males) bleeding disorder characterized by deficincy in a blood clotting factor (*factor VIII{A} or IX {B})

plateletsBleeding into the tissue

Bruising and

petichiaeMinimize bleeding

Prednisone: decreases antiplatelet antibodies

IVIG

Anti D antibody

Disorders of Hematological FunctionLeukemia -ALL (acute lymphoblastic leukemia) uncontrolled proliferation of blast cells,which accumulate in the marrow causing crowding and depression of other cells

• Hodgkins disease-This is a malignant lymphoma distinguished by painless, progressive enlargement of lymphoid tissue.

Assessment of the Immune System

Temperature for hyperthermia

Inspect skin for hives, edema, lesions

Conjunctival redness

Palpate for spleneomegaly

Assess the joints forSwelling, redness, Tenderness, decreasedmobility

Palpate foradenopathy

Auscultate for abnormalBreath sounds

Auscultate for tachycardia

Disorders of the Immune SystemInfection with HIV produces Lymphopenia resulting in immunosupression and AIDS

Symptoms may not Appear for 1 to 2 yrs• Nonspecific clinical manifestations

• Prevent opportunistic infections• Administer prophylactic therapy for P. carnii (co-trimoxazole) beginning at 6 mos of age• Immunizations• Pulmonary hygiene• Promote adequate nutrition• Foster healthy growth and development

Disorders of the Immune System

Clinical manifestations:• Daily afternoon

temperature spikes• macular rash on

trunk and extremities

• joint involvement- swelling, pain, redness

Medical management• Nonsteroidal anti-

inflammatory drugs• antirheumatic drugs• cytotoxic drugs• corticosteroids

Assessment of the Respiratory System

Temperature for hyperthermia

Inspect skin color changes, especiallycyanosis

Auscultate for abnormalBreath soundsMonitor respirations for rate, depth, and quality, Note any dyspnea, use of accessory musclesPercuss for dullness which indicates fluid

Observe forAlertness, changeIn mental status

Intercostsal, suprasternal, Sternal and substernalretractions

Chest diameter

Disorders of the respiratory system

Bronchopulmonary Dysplasia Premature lungs needing mechanical ventilation (high 02 and PIP) can injure the aveolar Saccules and lead to fibrosis of these structures

• Long term O2 therapy• Cyanosis when breathing RA• Manifestations of right sided failure

• Administer medications: bronchodilators, diuretic• Planned rest periods to decrease respiratory effort and conserve energy • Small frequent meals to prevent over distension of stomach• Counsel parents in ways to prevent respiratory infection• Teach parents CPR

Disorders of the respiratory system

• pneumoniaAcute inflammation of the lung parenchyma (bronchioles, alveolar ducts, and sacs, and alveoli)

Impairs gas exchange

• Antibiotics if bacterial• Assess for respiratory distress

• Provide family teaching

RespiratoryDistress

• Wheezing, crackles• Use of accessory

• muscles

Disorders of Respiratory Function-Bronchitis/Bronchiolitis

Viral infection of the lower respiratory tract characterized by inflammation of the

Bronchioles and production of mucous (usually caused by RSV)

• Wheezing• Crackles

• Tachypnea• Retractions

• Assess forrespiratory

Distress• Contact isolation

• Prescribed Medications (RT)• O2 if needed

• Fluids

Inflammation and edema of muscle (spasms) • Wheezing

• Use of accessory muscles

Production of thick mucosa resulting in increased airway resistance, premature closure Of airways, hyperinflation, increased work of breathing, impaired gas exchange

• Increased RR• Cough• Fatigue• Anxiety• dyspnea• Assess respiratory status

• Administer prescribed meds• Promote adequate O2

• Fowler’s position

Asthma is a chronic, reversible, obstructive airway disease, triggered by various stimuli

Disorders of the respiratory system

• Respiratory distress syndrome- mainly caused by a lack of a slippery, protective substance called surfactant, which helps the lungs inflate with air and keeps the air sacs from collapsing. Common in premature babies whose lungs are not fully developed.

• Sudden infant death syndrome• Acute pharyngitis (sore throat)-inflammation of the pharynx• Tonsillitis • Croup – inflamation of the larynx (voice box)** • Acute epiglotitis –bacterial infection of t he epiglottis• Pulmonary tuberculosis-chronic bacterial infection caused by bacillius

mycobacterium tuberculosis• Cystic fibrosis- an inherited disorder of the exocrine glands characterized by

excessive thick mucous that obstructs the lungs and GI tract

Assessment of the GI System

Temperature for hyperthermia

Inspect skin for pallor, jaundice, carotenimia

Inspect abdomen for distention, depression, umbilical herniationAuscultate to assess bowel sounds (do first)Palpate for tenderness, rigidity, masses and organomegaly

Inspect the anus for rectal bleeding and nonpatency

Inspect mouth For caries, periodontalDisease, lesions,And clefts

Palpate hard and soft palates for defects

Measure height And weight for growth failure

Disorders of Gastrointestinal FunctionCleft lip and cleft palate are birth defects that affect the upper lip and roof of the mouth. They happen when the tissue that forms the roof of the mouth and upper lip don't join before birth. The problem can range from a small notch in the lip to a groove that runs into the roof of the mouth and nose. This can affect the way the child's face looks. It can also lead to problems with eating, talking and ear infections.

Treatment usually is surgery to close the lip and palate. Doctors often do this surgery in several stages. Usually the first surgery is during the baby's first year. With treatment, most children with cleft lip or palate do well.

• Ensure adequate intake of food and fluids without aspiration.

• Special feeding devices may be used.

• Frequent burping is necessary.

• Assist parents in dealing with the diagnosis

Disorders of Gastrointestinal Function-constipation/dehydration

The passage of hardened stools; may be associated with failure ofcomplete evacuation of the colon withdefecation

• Add fluid or carbohydrate to the formula, add foods with bulk, and increase fluid intake.

• Manually dilate the sphincter; administer mild laxatives/enemas.

• Obtain history of bowel patternseducate on dietary changes and normal stool patterns.

Disorders of Gastrointestinal Function- diarrhea/gastroenteritis

• May be a result of a number of disease processes that cause abnormal losses through the skin, respiratory, renal, and GI systems –vomiting/diarrhea

• Diarrhea- A disturbance in intestinal motility characterized by an increase in frequency, fluid content, and volume of stools

• Assess for clinical manifestations of dehydration.

• Observations should include I&O; vital signs; body weight; skin color, temperature, and turgor; capillary refill; presence or absence of the sensation of thirst; and in infants, assessment of the fontanels.

• I&O, promotion of rehydration, correction of electrolyte imbalances, provision of age-appropriate nutrition, prevention of the spread of the diarrhea, prevention of complications, support of the child and family

Disorders of Gastrointestinal Function-

• Gastroesophageal reflux

• Hypertrophic pyloric stenosis

• Intusseception

• Hirschprungs disease

The backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the

lower esophageal sphincter

Narrowing of pyloric sphincter at the outlet of the stomach

Pyloromytomy:Relieves

obstruction

Telescoping of one portion of the Intestine into an adjacent portion

Causing an obstruction

Congenital anomaly characterized by absence of nerves to a section of the intestine causing inadequate mobilityWhich leads to the absence of propulsive movements,

causing accumulation of intestinal contents and distention of bowel

Disorders of Gastrointestinal Function-hernias

• Umbilical • Femoral• Inguinal• Hiatal • Diaphragmatic

A protrusion of the bowel through an abnormal opening in the abdominal wall

Most common in

children

Usually closes by the time the child is 3 years

old

Surgical repair

Assessment of the GU System

Temperature for hyperthermia

Inspect skin for peripheral cyanosis, slow cap refill time, pallor, peripheral edema

Monitor RR for abnormal rate and depth of respiration

Inspect the anus for rectal bleeding and nonpatency

Measure height And weight for growth failure

Monitor blood Pressure for hypoOr hypertension

Abdominal distension

Uremic encephalopathy-Lethargy, poor concentration, confusion

Hypospadias, epispadias

Ear abnormalities

Palpate kidneys for Tenderness, and enlargemnt

BladderFordistension

Disorders of Genitourinary Function-• UTI- characterized by inflammation, usually of bacterial origin, of the urethra, bladder,

ureters, or kidneys• Nephrotic syndrome- characterized by proteinuria, hypoalbuminemia, hyperlipidemia,

altered immunity and edema. Increased permeability to protein, protien leaks through the glomerular membrane resulting in albumin in the urine. Once albumin is lost colloidal osmatic pressure decreases permiting fluid to escape from the intravascular spaces to the intirstial spaces. The volume decrease stimulates antidiuertic hormone to reabsorb water = edema.

• Acute glomerulonephritis- antibodies interact with antigens that remain in the glomeruli, leading to immune complex formation and tissue injury, filtration decreases and excretion of less Na and H2O. High Blood pressure, edema, and heart failure may result.

• Wilm’s tumor-

• Structural defects of gu tract

Assessment of the EndocrineSystem

Inspect skin for color changes, hirsutism, easy bruisingPalpate to note dryness, coldness, changes in texture

Measure height And weight for growth Failure, plot size of head

Monitor blood Pressure for hypoOr hypertension

Lethargy, poor concentration, confusion, irritability

Assess for sexual development

Monitor pulseIncrease= hyperthyroidDecrease=hypothyroidAuscultate to note for murmurs

Assess vision

Facial abnormalities, mouth for abnormal odors andDental delay’s

Palpate hair & nails

Assess muscle Strength and tone

Disorders of Endocrine Function

• Hypothyroidism• Hyperthyroidism

• Diabetes mellitus

A chronic conditionCharacterized by inadequate amount of thyroid hormone to meet metabolic needs. Congenital- T4 is not produced which is essential for growth and development especially brian development, left untreated = MR.Acquired- inadequate amount of T4

A chronic metabolic disorder that results from either a partial or complete deficiency in insulin. Type 1- characterized by beta cell destruction, leading to absolute insulin deficiency.Type II- insulin resistance, progressive deterioration of Insulin secretion

3 p’s• Polydipsia• Polyuria

• Polyphagia

Assessment of the Musculoskeletal SystemMeasure height And weight for growth

Inspect posture and gait

Observe for structural abnormalitiesAsymmetrical limbs

Palpate boneyStructures for tenderness,Masses, lesions

Palpate spine to assess curvature

Assess, muscle mass, tone

Disorders of Musculoskeletal Function

A spinal deformity that usuallyInvolves lateral curvature of theSpine, spinal rotation, and thoracic Kyphosis (hunch back)

Surgery to correct

A disorder caused by decreased blood supply to the femoral head; results in epiphyseal necrosis and degeneration

Legg-Calvé-Perthes Disease • Developmental Dysplasia of the Hip

A developmental abnormality

of the femoral head, the acetabulum,

or both; subluxation of the hip

Scoliosis

Disorders of Musculoskeletal Function

• Congenital deformity of the foot and ankle• Varies in severity; may involve one

foot or both feet• Manipulation and application of a

series of short leg casts; changed weekly to allow for further manipulation

Talipes (Clubfoot)

Osteomyelitis

• Infection within the bone• In children, the metaphysis of the femur,

the tibia, and the humerus are the areas most affected.

• It can occur at any age; the peak incidence in children is between ages 3 and 15 years, and boys are affected twice as often as girls.

Disorders of Musculoskeletal Function

• Duchenne’s Muscular DystrophyA sex-linked inherited

disorder characterized by gradually progressive

skeletal muscle wasting and

weakness

No effective treatment

Septic Arthritis

An infection of a joint,

which can occur from

bacteria in the blood or

as a direct extension of

an existing infection

Joint aspiration and surgical irrigationBroad-spectrum

IV antibiotics

Fractures

Most common sites in children are

long bones, clavicles, wrists, fingers,

and skull.

Assessment of the Neurological SystemMeasure head size, Palpate fontanels

TachycardiaIncreased ICP

HypertensionIncreased ICP

Assess LOC,Cerebullar status- gait Balance and coordination

Cranial nerve functionEsp pupillary response,Taste, olfaction, and tactile sense

Assess muscle tone and strength

Assess reflexes

Disorders of Neurological FunctionAn infection of the meninges that is usually caused by bacterial invasion and less Common by viruses. The bacteria Enter the meniges through the blood stream and spread through the csf.

Children under 2- poor feeding, irritability And lethargy, high pitched cry, bulging

Fontanel, fever, resistance to being held,Opisthotonos (hyperextension of the Neck)

Older children- respiratory or GI problems, nuchal rigidity (stiff neck), HA, kernigs sign,

bruzinski sign, petichial rash• Check for neurolical signs

and monitor LOC• Administer prescribed meds(antibiotic, steroid for cerebral

Edema, anticonvulsant)• Keep room quite and decrease

Environmental stimuli

Meningitis

Disorders of Neurological FunctionA condition caused by an imbalance in the production and absorption of CSF In the ventricular system. When production exceeds absorption, CSF Accumulates, usually under pressure andProduces a dilation of the ventricles.

Occurs with a number

of anomalies

Communicating hydrocephalus- an impaired Absorption of CSF in the arachnoid space

Noncommunicationg hydrocephalus- obstruction to the flow of CSF through the ventricular system

Increased ICP- HA, emesis, irritability, Lethargy, apathy, and confusion

Disorders of Neurological Function

Surgical treatment- removal of obstruction and insertion of shunts to provide primary drainage of the CSF to an extracranial compartment, usually the peritoneum (ventriculperitonel shunt or VP shunt)

Disorders of Neurological FunctionSpina Bifida

Defective closure of the vertebral Column that may occur anywhereBut usually occurs in the lumbosacral area.

• Occulta- does not affect spinal cordMay be dimpling of the skin, nevi,

hair tuft

• Meningocele- sac consisting of meninges and CSF protruding

outside the vertebrae. The spinalcord is not involved

Myelomeningocele (most common)-Similar to meningocele but spinal Cord and nerve roots are involved Resulting in sensorimotor deficits,

Urinary and bowel problems

No cure. Surgery to minimize infection. Preoperatively- apply a sterile dressingTo the lesion and constantly moisten it

With saline. Use protective devicesAnd handle infant with care.

Disorders of Neurological Function• Encephalitis- An inflammation of the CNS, mainly the brain and spinal cord

• Cerebral palsy- group of disabilities caused by injury or insult to the brain either before or during birth

• Seizure disorders- disturbances in normal brain function that result in abnormal electrical discharges in the brain, which can cause LOC, uncontrolled body movements, changes in behaviors and sensation, and changes in the autonomic system.

Many underlying causes:• Prenatal or perinatal hypoxia

• Infection• Congenital malformaiton• Metobolic disturbances

• Lead poisoning• Head injury

• Tumor• Medication

• Toxin exposure

• Administer prescribed meds• Prevent injury

• Document all seizure activity

Disorders of IntegumentaryFunction

• Contact – inflammation of the skin• Diaper- form of contact dermatitis, exposure

to feces and urine

• Atopic (eczema)- a pruritic response

• Seborrheic – cradle cap

resulting from contact with environmental antigens

AntihistaminesClip fingernails

Keep the diaper area clean and dry; change diapers as soon as possible;

cleanse area with mild soap and water, pat dry.

Hydration of the skin; control pruritus;

decrease inflammation; and prevent secondary infections.

Crusts should be soaked with warm water and compresses until loosened; shampoo and rinse.

Disorders of Integumentary Function• Acne Vulgaris – inflammatory process of the skin commonly seem in adolescents

• Psoriasis- a chronic proliferative skin disorder characterized by thick, scaly patches and inflammation

• Herpes Simplex – a common infection, transmitted by direct contact of infected body fliuds with nonintact skin or mucous membranes• Candidiasis (thrush)-white patches of candida frequently found on moist tissues, tongue, buccal cavity, vagina

meticulous skin careis emphasized

Nystatin suspension; administer after

feedings.Inform parents that the

full 7-day course of nystatin is to

be completed.Teach parents to sterilize

bottles, nipples, pacifiers, and teethers

Disorders of Integumentary Function• Parasitic infections –scabies, head lice

• Bacterial Infections- impetigo, folliculitis, and cellulitis

The assessment of systemic

signs and symptoms, areas involved, and appearance

of lesions are helpful in establishing the type of infection.