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