SELECTED PEDIATRIC DISEASES

Respiratory Anatomy & Physiology

• The respiratory system consists of two main parts- the upper and the lower tracts

Respiratory Anatomy & Physiology

The UPPER respiratory system consists of:

• 1. nose• 2. sinuses• 3. mouth• 4. pharynx• 5. larynx• 6. epiglottis

UPPER RESPIRATORY TRACT INFECTION

ACUTE NASOPHARYNGITIS (CORYZA)

• Most frequent infectious disease in children

• Average of 10-12 colds/ year

• Incubation period- 2-3 days

• The COMMON COLDS

1. Rhinovirus-most common cause

2. Parainfluenza virus

3. Respiratory syncytial virus (RSV)

4. Adenovirus

5. Influenza virus

6. Coxsackie virus

ETIOLOGIC AGENT

SIGNS AND SYMPTOMS

1. nasal congestion

2. watery rhinitis

3. low grade fever

4. mucus membrane is edematous

5. cervical lymph node may be swollen and palpable

6. body malaise

TREATMENT

• Common colds is self-limiting

• supportive care

• relief of nasal obstruction - use of isotonic saline drops and aspiration

• antipyretic or analgesic agents

• antitussive is sometimes used for persistent cough

StreptococcalPharyngitis

• Strep throat• Spread by infected nose or throat mucus

through coughing or sneezing

S/sx: pain on swallowing, fever, headache, swollen lymph nodes, swollen hyperemic tonsils w/ OR w/out pus

Dx: throat SWAB and culture & sensitivity

Group A beta-Hemolytic Streptococcal Bacteria – Gram (+) bacteria

1. antibiotics- 10 day-course of oral antibiotics (Pen G or Clindamycin)

2. high fluid intake

3. relief of pain

• COMPLICATION: Rheumatic Fever, Rheumatic Heart Disease, Acute Glomerulonephritis

TREATMENT & MANAGEMENTPHARYNGITIS

TONSILLITIS

term commonly used to refer to infection and inflammation of palatine tonsils

palatine tonsils - located on both side of pharynx

Adenitis - refers to infection and inflammation of the adenoids ( pharyngeal) tonsils

adenoids - located in the nasopharynx

Tubal tonsils - located at entrance to the Eustachian tube

Lingual tonsils - located at base of tongue

• <3 years old - often viral

• school age children – often bacterial

ETIOLOGY

Signs and Symptoms

1. difficulty of swallowing (dysphagia)

2. painful swallowing (odynophagia)

3. fever

4. lethargy

5. mouth breathing

6. difficulty hearing (Eustachian tube)

7. halitosis

8. sleep apnea

TREATMENT

1. antipyretic

2. analgesics

3. Antibiotics ( 10 day course – usually Penicillin but may be Erythromycin if allergic to penicillin) is prescribed for bacterial infections to prevent the complication of rheumatic fever.

4. Surgical – tonsillectomy with adenoidectomy

INDICATIONS FOR TONSILLECTOMY

1. chronic tonsillitis (not done if inflamed

because may spread infection)

2. Recurrent tonsillitis (4-6x/year)

3. Peritonsillar Abscess

4. Sleep apnea

Nursing diagnosis: Pain related to Surgical Procedure

TONSILLECTOMY

Post –op Care:• 1. Observe for, & report unusual bleeding

( frequent swallowing)• 2. Help prevent bleeding by discouraging the

child from coughing & clearing the throat.• 3. Position the child on the side or the

abdomen (prone) to facilitate drainage from the throat

TONSILLECTOMY

• 4. Provide appropriate teaching . Instruct the child & parents to:

• a. Observe activity restrictions, especially upon the child’s return to school.

• b. Avoid persons with known infections.• c. Avoid acidic & other irritating foods.• d. Monitor the child for bleeding, especially

immediately postoperatively & 5 to 10 days post op when tissue sloughing

occurs.

EPISTAXIS

1. keep pt in upright position with head tilted slightly forward to minimize the amount of blood pressure in nasal vessels, keep blood moving forward not back to nasopharynx

2. apply pressure to the side of the nose with your fingers, may have ice compress

EPISTAXIS

3. Ask the child to stop crying because crying increases pressure in the blood vessels of the head and prolonged bleeding

4. control of bleeding, can give epinephrine

(1:1000) to constrict blood vessels

5. can put nasal packing for continuous pressure on the site of the ruptured blood vessel

Epiglottitis

• Inflammation of epiglottis ("cherry-red“)

• Hemophilus influenza type B

• 2-7 yo

Pathophx: upper respiratory infection inflammation of epiglottis

EPIGLOTTITIS

S/sx: high fever, sore throat, cough hoarseness, drooling, dysphagia

Dx: CBC, elevated c-reactive protein (CRP), culture of epiglottis, neck xray

> it is considered an emergency because the swollen epiglottis is not allowing the airway to open.

- this emergency situation occurs most commonly in children between 3 and 6 years of age.

E P I G L O T T I T I S

NURSE ALERT!!! “ Never illicit gag reflex-may cause complete obstruction”

Nsg Dx:

Ineffective breathing pattern r/t inflammationIneffective airway clearance r/t inflammationParental anxiety r/t respiratory distress in child

MANAGEMENT• Emergency treatment (intubation)• Moist air• hydration• O2• Antibiotics – chloramphenicol, co-amoxiclav• Assurance to avoid agitation

LOWER RESPIRATORY TRACT INFECTION

Respiratory Anatomy & Physiology

The LOWER respiratory system consists of:

• 1. Trachea

• 2. Bronchus

• 3. Bronchioles

• 4. Respiratory unit

The BRONCHI• RIGHT BRONCHUS

• Wider• Shorter• More Vertical

• LEFT BRONCHUS

• Narrower• Longer• More horizontal

Retraction

• Supraclavicular/ Suprasternal retraction - suggest upper airway obstruction

• intercostal retraction- suggest lower airway obstruction

Bronchitis

• Inflammation of bronchi • Starts as URTI

S/sx:• initially low grade fever, colds • 3-4 days after, roughening breath sounds, rales, dry,

hacking unproductive cough • Cough w/ sputum production - clear to purulent,

dyspnea, chest pain

BRONCHITIS

Dx: clinical

Elevated C-reactive protein (CRP) – bacterial

Mgmt:

rest

CPT

Fluids

antibiotics

BronchitisViral Bacterial

Etio Rhinovirus,Influenza,

RSV, Parainfluenza

adenovirus, paramyxovirus

S. pneumoniae,

S. aureus,

H. Influenzae,

M. Catarrhalis

S/sx Rhinitis, cough, malaise, chills, mild fever, sore throat

higher fever and a more prod cough

Dx Clinical

Xray – normal

Elev c-reactive CHON

Course Mild & self-limiting Up to 2 weeks

Rx supportive empirical; amox-tetracycline, erythromycin

Bronchiolitis

• inflammation & swelling of bronchioles w/ mucous in airways

• RSV,parainfluenza, Adenovirus, influenza

• 0-2 yo, peak 6 mos old

• transmitted via droplets

Pathophx:

mild upper respiratory infection edema of airway and accumulation of mucus airway narrowing hypoxemia

S/sx: wheezing, tachypnea, wet hoarse cough, fever, poor appetite, difficulty sucking, restless sleep, retractions

Dx: cxr, pulse oximetry, throat culture

BRONCHIOLITIS

BRONCHIAL ASTHMA

• chronic, reversible , obstructive airway disease, characterized by wheezing. It is caused by smooth muscle spasm w/ hypertrophy of the bronchial tubes, or swelling of the bronchial mucosa, after exposure to various stimuli.

Hypersecretion of mucus Most common chronic disease in childhood. Most

children experience their first sx by 5yo• exercise, nocturnal occurrence, seasonal, hx of allergy,

stress

Types of Bronchial Asthma

A. Extrinsic or Atopic Asthma: r/t external allergens such as:

• -contactants: dust, chemicals, soaps, perfumes, lotions, make-up

• -inhalants: dust, hay, scents, smoke, sprays• -ingestants: food, milk, chicken, beef, pork, eggs, etc.• -Sudden changes in temperature

Types of Bronchial Asthma

B. Intrinsic or Non-Atopic Asthma= not r/t external allergens

Stress

Fatigue

Lack of Sleep

Anxiety

C. MIXED type of Asthma= both types present

Pathophysiology of Asthma

• Heredity + Allergens &/or Stress

• Release of IgE from B lymphocytes

• IgE + Mast cells of respiratory tract = damage to mast cells

• Release of: Histamine, Bradykinin, Serotonin, Leukotriennes, Prostaglandins, ECF-A, SRS-A from damaged mast cells to respiratory membranes

Bronchial Asthma

• =S-ecretions: copious, viscous, sticky, stringy, whitish

• =S-pasms: laryngo-tracheo-bronchial spasm• =S-welling: edema of the airway

• Airway Obstruction

•

Dyspnea

Signs & Symptoms of Bronchial Asthma

• Successive episodes of coughing: dry, hacking, non-productive cough

• Increased respiratory secretions: whitish, stringy• Wheezing on expiration• Prolonged expiration• Dry lips and mucous membranes (mouth)• Dyspnea, Tachypnea, Tachycardia• Apprehension and restlessness

Nursing Interventions

Long-term Goal: Patient will achieve an open airway and adequate ventilation as manifested by normal VS and relief of symptoms

Short-term Goal:a. Liquify secretions

b. Easily expectorate and drain secretions

c. Relieve spasms

d. Decrease swelling of airways

Nsg Dx:

Impaired Gas Exchange r/t bronchiolar obstruction, atelectasis and hyperinflation

Parental anxiety r/t respiratory distress in child

Management• nebulization• hydration• O2 • positioning• TSB• Monitor VS esp RR• support

Pneumonia• Inflammation of lung parenchyma

Bacterial and atypical pathogens:NB – GBS, Gr (-) bacilli, chlamydiaChildren – S. pneumoniae, H. Influenzae, M. catarrhalisAdolescents – S and M Pneumoniae, M. catarrhalisHospital acquired – Pseudomonas, Klebsiella, E. Coli,

Enterobacter sp

Viral Pneumonia - RSV, Parainfluenza, Adenovirus, Influenza

Pathophx: aspiration/hematogenous/inhalation

alveoli inflammation hypoxemia

S/sx: fever, chills, cough, irritability, poor feeding, restlessness, headache, GI sx, tachypnea, use of accessory muscles, decreased BS, crackles, dullness on percussion, chest retractions

Dx: cxr, blood and sputum c/s

PNEUMONIA

UncommonCommonCommonInc RR

Non-toxicVariableToxicToxicity

Low-gradeVariableHighFever

InsidiousVariableAbruptOnset

5-15 yoAnyAnyAge

AtypicalViralBacterialParameter

UncommonCommonCommonInc RR

Non-toxicVariableToxicToxicity

Low-gradeVariableHighFever

InsidiousVariableAbruptOnset

5-15 yoAnyAnyAge

AtypicalViralBacterialParameter

AtypicalViralBacterialPerimeter

UncommonvariablecommonInc WBC

Fine crackles, wheezing

variable(+) consolidationfew crackles

PE

Bullous myringitis, pharyngitis

Mild coryzaMild coryzaAssoc sx

Non prodNon prodProductiveCough

AtypicalViralBacterialPerimeter

UncommonvariablecommonInc WBC

Fine crackles, wheezing

variable(+) consolidationfew crackles

PE

Bullous myringitis, pharyngitis

Mild coryzaMild coryzaAssoc sx

Non prodNon prodProductiveCough

Nsg Dx:• Ineffective breathing pattern r/t physiologic effects

of Pneumonia

- O2, monitor VS, CPT, encourage coughing and deep breathing

• Risk for deficient fluid volume r/t diminished oral intake and increased insensible fluid losses sec to diaphoresis, dyspnea and fever

- weigh and monitor daily, sips of fluid, temp control, monitor I and O

PNEUMONIA

• Activity Intolerance r/t effects of Pneumonia and Tachypnea

- rest periods, O2, small frequent feedings, gradual increase in activity, support and contact with family

Tuberculosis• High incidence in infancy and adolescence

• Primary Complex – based on xray; first encounter of a child w/ TB; Ghon’s tubercle w/ lymphangitis and regional (hilar) lymphadenopathy

• Primary Pulmonary TB – clinical TB

• d/t Mycobacterium TuberculosisDx: exposure, s/sx (2 or more), PPD, Chest Xray,

sputum AFB test

POSITIVE PPD TEST

Classification of TB

Class I TB exposure – (+) exposureClass II TB infection – (+) exposure and PPDClass III TB disease – active TB or 3 or more of

criteria Exposure, s/sx, (+)

tuberculin test, xray, sputum exam, culture

Class IV TB inactive – (+/-) hx of prev TB, (+/-) hx of prev hx of chemotherapy,

(+)xray evidence of healed lesion and (+) PPD

S/sx: fever, wt loss, cough, anorexia, night sweats, painless lymphadenopathy

Tx: Intensive INH, Rifampicin, PZA x 2 mos

Maintenance INH, Rifampicin x 4 mos

Respiratory Distress Syndrome

• Preterm, infants of diabetic mothers, C/S, hx of asphyxia

S/sx: inc RR, chest retractions, nasal flaring,expiratory grunt, cyanosis, HPN, hypothermia

Dx: ABG, Xray

Mgmt: surfactant replacement, O2, ventilation, supportive care

Decreased surfactant

lungs collapse

Inc pulmonary resistance

blood shunts through F.O. and D.A.

poor lung perfusion and gas exchange

further decrease in surfactant hypoxia

acidosis

Cardiovascular Disorders

Fetal Circulation

• placenta provides the exchange of gas and nutrient

• four shunts in fetal circulation:– Placenta– Ductus venosus– Foramen Ovale – Ductus arteriosus

CONGENITAL HEART DEFECTS

• CHD are structural defects of the heart, great vessels, or both that are present at birth.

• Children with CHD are more likely to have associated defects such as tracheoesophageal fistula (TEF)

• CHD is second only to prematurity as a cause of death in the first year of life.

1.Acyanotic Heart Disease L R shunt high pressure to low pressure oxygenated to unoxygenated blood

2. Cyanotic Heart Disease R L shunt

low pressure to high pressure

3. Obstructive Defects

CONGENITAL HEART DEFECTS

ACYANOTIC HEART DISEASE1. Atrial Septal Defect

• Opening between atria• late childhood/early adulthood• S/sx: cyanosis(CHF), dyspnea,

fatigue, failure to thrive, split S2

• Mx: Abx, surgery 1-3 yo• Cx: endocarditis, heart

failure• Postop: monitor arrhythmia,

administer antibiotics

ACYANOTIC HEART DISEASE2. Ventricular Septal Defect

• Opening in ventricular septum

• Most common• S/sx: respi infections, failure

to thrive, dyspnea, fatigue, pansystolic murmur

• Mx: close spontaneously otherwise surgery <2 yo

• Cx: pulmonary HPN, endocarditis, heart failure

• Postop: monitor arrhythmia, administer antibiotics

ACYANOTIC HEART DISEASE3. Patent Ductus Arteriosus

• Aorta to pulmonary artery• Common in prematurity,

high altitude, maternal rubella

• females• S/sx:clubbing, dyspnea,

“machinery murmur” (2nd-3rd ICS)

• Cx: heart failure, endocarditis, pulmonary artery stasis/HPN

• Mx: Indomethacin, surgery

CYANOTIC HEART DISEASE1. Tetralogy of Fallot (TOF)

• S/sx: cyanosis, clubbing, dyspnea, fatigue, squatting, “Tet spells”, failure to thrive, systolic murmur, polycythemia

• Cx: thromboembolism, CVA• Mx: O2, knee-chest position,

surgery 1-2 yo• Postop: monitor for arrhythmia Blalock Taussig: anastomose SC

and pulmo art. - avoid BP and venipuncture in right arm

CLUBBING IN TETRALOGY OF FALLOT

CLUBBING OF THE FINGERS

CYANOTIC HEART DISEASE2. Transposition of the Great

Vessels

• Aorta from R ventricle• Pulmonary a. from L

ventricle• Males• S/sx:cyanosis,

murmurs• Mx: PGE for PDA,

Balloon catheter to create ASD, definitive surgery 1 wk-3 mos

CYANOTIC HEART DISEASE3. Total Anomalous Pulmonary

Venous Return

• Pulmonary vein drain to SVC or R atrium

• PDA or foramen ovale essential

• S/sx: cyanosis, fatigue

• CX: R heart failure• Mx: PGE, surgery

OBSTRUCTIVE DEFECT Coarctation of the Aorta

• Constriction of aorta• S/sx: asymptomatic HPN,

irritability, headache, epistaxis, dyspnea, claudication, higher BP in upper extremities, dec femoral and distal pulses,systolic murmur

• Cx:chronic HPN• Mx:surgery 2 yo• Postop: monitor

abdominal pain, antihypertensives

Ndx: Ineffective cardiopulmonary and peripheral tissue

perfusion related to impaired cardiac function • Proper positioning to maintain respiration• Conserve energy to promote rest• Quiet activities and stimulation• Anticipate needs• Administer prescribed drugs

COARCTATION OF THE AORTA

Activity intolerance r/t effects of congenital heart defect and dyspnea

• Rest periods• Adequate nutrition small frequent feedings iron supplementation

COARCTATION OF THE AORTA

Obstructive Defect2. PULMONIC STENOSIS

Obstruction of blood flow from the right ventricle to the pulmonary artery

PULMONIC VALVE

Backflow of blood towards the right ventricle

Right Ventricle has to PUMP HARDER to push the blood to the pulmonary artery for Oxygenation

RIGHT VENTRICULAR ENLARGEMENT

RIGHT-SIDED CONGESTIVE HEART FAILURE

Obstructive Defect3. AORTIC STENOSIS

• Involves an obstruction of the ventricular outflow of the blood

• S/SX: faint pulse, hypotension, tachycardia, poor feeding, exercise intolerance, chest pains

• DX; ECG, Echocardiography reveals left ventricular hypertrophy.

• MX:• Surgical aortic valvulotomy or prosthetic valve

replacement.• - Balloon Angioplasty to dilate the narrow valve.

Obstructive Defect3. AORTIC STENOSIS

Obstruction of flow to the AORTA• AORTIC VALVE

Backflow of blood towards the LEFT VENTRICLE

Left Ventricle has to PUMP HARDER to push the blood to the AORTA for distribution of oxygenated blood

LEFT VENTRICULAR HYPERTROPHY with Regurgitation of oxygenated blood back to the LUNGS

LEFT-SIDED CONGESTIVE HEART FAILURE (Respiratory Signs)

Kawasaki Disease/Mucocutaneous Lymph Node

Syndrome

• Before puberty, peaks 4 yo

• S/sx:spiking fever x 5 days, bilateral conjunctivitis, reddened pharynx, dry lips, strawberry tongue, cervical lymphadenopathy, peripheral edema, erythema and desquammation, truncal rash, arthritis

• Patho: Respi infection immune complex systemic vasculitis aneurysm and MI

• Dx: clinicalMx: Salicylates and Immunoglobulins

KAWASAKI DISEASE

• Risk for ineffective peripheral tissue perfusion related to inflammation of blood vessels

- Observe for chest pain, color changes, vomiting

• Pain r/t swelling of lymph nodes and inflammation of joints

- Comfort measures, administer pain medications

KAWASAKI

KAWASAKI

Other Measures:

Protect edematous areas

Record intake and output

Offer soft food

Administer prescribed medication

Rheumatic Fever

• Autoimmune• Grp A Beta hemolytic strep• 6-15 yo, peaks 8 yo• 1-3 wks after untreated infection• Dx: 5 major criteria –

polyarthritis, carditis, subcutaneous nodules, erytHema marginatum, sydenham’s chorea

minor – fever, polyarthralgia, hx of RF, inc ESR, antecedent strep infection

• To diagnose, either 2 major or 1 major and 2 minor

present• Cx:mitral valve insufficiency and

myocarditis

J. N. E. S.

RHEUMATIC FEVER

Mgmt: salicylate, penicillin

Ndx:

Risk for noncompliance r/t knowledge deficit about importance of long term therapy

- prevent initial and recurrent attacks

Decreased cardiac output r/t disease process- bed rest, comfort and appropriate activities

RHEUMATIC FEVER

Nursing Care

• Monitor vital signs

• Provide adequate nutrition

• Promote safety to prevent chorea related injuries

Gastrointestinal Disorders

Cleft Lip and Palate

• failure of fusion of maxillary and median nasal process

• hereditary• unilateral/bilateral• Males

Mx: surgery - Cheiloplasty• Rule of 10’s- AGE=10 wks,

WT=10 lbs, HgB=10 gm

Cleft Palate

• midline opening of palate

• usually w/ Cleft lip• Female• surgery 6-18 mos -

allow anatomic changes <1 yo ie formation of palatine arch and tooth buds

Ndx:• Risk for imbalanced nutrition, less than

body requirements r/t feeding problems• Risk for ineffective airway clearance r/t

oral surgery• Risk for infection during post op period

Nursing CarePreop• Adequate nutrition; sips of fluid btw feeding in

upright position; use rubber tipped syringe; Burp • Prevent ear and upper respiratory tract infection• Address body image and speech concerns• Reassurance to parents

Postop• monitor respiratory distress d/t edema,

hemorrhage• Suction mucus and blood gently• dropper feeding 1st 3 weeks; regular feeding after• Anticipate needs and position to prevent tension

on sutures • Position side lying in cleft lip; prone in cleft palate

Tracheoesophageal Fistula

• Communication of the esophagus and trachea• maternal hydramnios and prematurity• S/sx:coughing, choking, cyanosis, dyspnea,

excessive secretion, abdominal distention• Dx: Ba swallow

TEF

Ndx:• Risk for imbalanced nutrition, less

than body requirements r/t inability for oral intake

• Risk for infection r/t aspiration or seepage of stomach contents into lungs

• Risk for impaired skin integrity r/t gastrostomy tube insertion site

Nursing carePreop• Suction regularly• Elevate the head• Gastrostomy feeding• hydration• O2

Postop

1. Observe for respiratory distress

2. Proper positioning –avoid hyperextension of neck

3. Continue suction

4. Prevent wound infection

5. Provide pacifier

Hirschprung’s Disease

• Aganglionic megacolon• Absence of innervation to a

bowel segment usually rectosigmoid colon

• No peristaltic activity in affected area

• Familial• males• S/sx:constipation,

ribbonlike stools or no meconium, abdominal distention, vomiting

• Dx: Ba enema, biopsy• Mx:colostomy, surgery

HIRSHSPRUNG’S DISEASE

Ndx:

• Constipation r/t reduced bowel function

• Imbalanced nutrition, less than body requirements r/t reduced bowel function

Nursing CarePreop1. Daily enemas w/ 0.9% NaCl *Tap/hypotonic water will cause cardiac

congestion or cerebral edema2. Minimal residue diet w/ vitamin supplementation3. Position semi fowlers to relieve dyspnea from

distended abdomen4. pacifier

Postop1. Observe for abdominal distention2. Small frequent feedings after NGT removal3. Colostomy care4. Assist parents to cope with children’s feeding

problems

Intussusception• 2-6 mos• Invagination of intestine < 1 yo – idiopathic

> 1 yo – “Lead point”• S/sx:intense abdl pain,

vomiting, blood in stool “currant jelly”, abdominal distention (sausage shaped mass)

• NECROSIS: fever, tachycardia, rigid abdomen

• Dx:sonogram “coiled spring”• Mx:Ba enema (reduction by

hydrostatic pressure), surgery

Ndx:• Pain r/t abnormal abdominal peristalsis• Risk for deficient fluid volume r/t bowel

obstruction • Nsg care:

1. NPO

2. Adequate hydration via IV therapy

3. Promote parent-infant bonding

4. Provide comfort measures - pacifier for infants

• Hypertophy/hyperplasia of pyloric sphincter

• Males• S/sx:nonbillous vomiting,

s/sx of of dehydration and wt loss, abdominal distention, “olive” sized mass RUQ, visible peristalsis

• Dx:xray-”string sign”, USG, endoscopy

• Mx: surgery

Pyloric Stenosis

PYLORIC STENOSIS

Ndx:• Risk for deficient fluid volume r/t

inability to retain food• Risk for infection at site of

surgical incision r/t danger of contamination from feces d/t proximity of incision to diaper area

PYLORIC STENOSIS

Postop1. dropper feeding 4-6 hrs after surgery 45 min-

1 hr duration; oral rehydration soln then half strength breastmilk/formula at 24 hr interval

2. Side lying position

3. Monitor weight and return of peristalsis

4. Wound care

5. Pacifier for oral needs

Celiac Disease/Gluten sensitive Enteropathy/Celiac Sprue

• Malabsorption syndrome that occurs when the mucosa of the proximal small intestine is sensitive to gluten. (wheat, rye, oats, barley)

• inability to absorb fat, thus steatorrhea, deficient fat soluble vitamins, malnutrition and distended abdomen

• S/Sx appears bet 1-5 yo after introduction of gluten in the diet.

• S/sx:diarrhea, wt loss, anorexia, irritability, anemia (Fe deficiency)

Celiac Disease

Pathophysiology:• Intolerance for or inability to digest gluten

>>>accumulation of the amino acid glutamine>>>toxic to intestinal mucosal cell>>> intestinal villi atrophy >>>reduction of absorptive surface of the small intestine.

Celiac Disease

• CELIAC CRISIS (due to ingestion of gluten, infections, prolonged fasting) = acute vomiting and diarrhea & may lead to F & E imbalance & rapid dehydration.

• Dx: Biopsy of the jejunum reveals the mucosal surface with hyperplastic villus atrophy. ( Definitive diagnosis of celiac disease). This characteristic lesion return to normal after dietary restriction of gluten which helps confirm the dx.

• Mx: hydration, gluten free diet, vitamin & Fe supplementation , avoid cereals, bread, cake, cookies, spaghetti, pizza, instant soup, some chocolates, some ice cream, donuts, pies, hotdogs,

Celiac Disease

Foods allowed:• 1. Meats: beef, pork, poultry & fish• 2. Eggs• 3. Milk & dairy products: milk, cheese,

cream• 4. Fruits & veg: all• 5. Grains: rice, corn, gluten free wheat flour,

corn flakes, corn meal & gluten free pre-cooked cereals

Diaphragmatic Hernia

• Herniation of intestinal content into the thoracic cavity

• Left side• S/sx:respiratory difficulty,

cyanosis, retractions, (-) breath sounds affected side, scaphoid abdomen

• Cx: pulmonary HPN• Mx: ’E’ surgery

DIAPHRAGMATIC HERNIA

Ndx:Risk for ineffective airway clearance r/t

displaced bowelRisk for imbalanced nutrition, less than

body requirements, r/t NPO status

Nursing Care

Preop• Elevate head • Low intermittent suction

Postop1. Semi-fowlers

2. Maintain warm, humidified envt – lung fluid drainage

3. Suction prn

4. Chest pptx

5. NPO – prev pressure on diaphragm

Necrotizing Enterocolitis

- Bowel develops necrotic patches, interfere w/ digestion, lead to paralytic ileus, peritonitis and perforation

- D/t ischemia sec shock or hypoxia, infection, immature GIT immune protection

S/sx: abdomen tense and distended, stool (+) for occult blood, > 2 ml gastric residual, bradycardia, apnea

Dx: abdominal xray

Mgmt: d/c feeding, IV or TPN, Antibiotic, colostomy, surgery for perforation

Inguinal Hernia

• Protrusion of a bowel through the inguinal ring

• males• S/sx: painless lump in the

groin • Cx: bowel strangulation• Mx: surgery <1 yo • Post op Nursing care:

wound care

assess circulation in the

leg

Cystic Fibrosis

• Autosomal recessive• Dysfunction of exocrine glands; inc viscosity

of mucous glands • Affects lungs, pancreas, intestines and sweat

glands• S/sx: GI - meconium ileus, rectal prolapse,

steatorrhea, malnutrition, failure to thrive

Respiratory – recurrent infection,cough, dyspnea, clubbing, cyanosis

Sweat Gland – ”salty taste”

Other – males infertile, abnormal glucose tolerance

Dx: history, sweat test (NaCl 2-5x the normal), absence of pancreatic enzymes, immunoreactive trypsinogen in blood and pulmonary involvement

Mx: chest physiotherapy, antibiotics, pancreatic enzymes, vitamins, lung or pancreas transplant

CYSTIC FIBROSIS

Ndx:

• Imbalanced nutrition, less than body requirements r/t inability to digest fats

• Ineffective airway clearance r/t inability to clear mucus from the respiratory tract

Nursing Care

1. Hi calorie, Hi CHON, moderate fat diet

2. Nebulization and physiotherapy

3. Frequent Position changes when in bed

4. Oral care

5. Adequate rest and comfort

Neurological Disorders

Brain Tumor

• Second most common form of cancer in children• 1-10 yo, peak 5 yo• Usual location - brainstem or cerebellum• TYPES:

Astrocytoma- glial tissue; 5-8 yo

Medulloblastoma – cerebellum; 5-10 yo; cause compression of 4th ventricle; most common

Brain stem tumor – support tissue of neural cells; paralysis of 5th-7th, 9th-10th CN

S/sx: headache, vision changes, vomiting, enlarging head circumference, papilledema, lethargy, ataxia, nystagmus, personality changes, seizures, lethargy, coma

Dx: skull films, bone scan, CT scan, Lumbar puncture, MRI, angiography

Mx: surgery, chemotx

BRAIN TUMOR

Preop1. Stool softeners2. Dexamethasone3. Dilantin 4. Shave head5. Prepare patient and family

psychologically

BRAIN TUMOR

Postop1. Proper position – low fowler’s2. Anticipate needs3. Saline eye drops as needed4. Monitor VS and NVS5. Regulate IV6. Observe head dressings7. Provide comfort and opportunity for self

expression

BRAIN TUMOR SURGERY(CRANIOTOMY)

Benign Febrile Seizure

• 6 mos - 5 years • fever >/= 38.5C• generalized tonic-clonic • rarely persist > 10 minutes• Postictal stage• 30-40 % recurrence• (+) family history

CONVULSION/SEIZURE

NURSING CARE

• Turn child to side & allow to drool

• Do not restrain

• Do not put anything in the mouth

• Dec temp

• Refer if:

sx persist

another sx occurs

delirious/difficult to rouse after sx

Erb Duchenne’s Paralysis

• Damage on C5-C6 due to birth trauma• Unilateral• S/sx: shoulder adducted, internally

rotated, elbow extended, forearm pronated and the wrist flexed “waiter’s tip”, (-) moro reflex

• Mx: PT, surgery• Nsg care: advise exercise and frequent

follow up

ERB DUCHENE’S PALSYC5 & C6

Cerebral Palsy• Damaged motor function d/t anoxic brain injury

secondary to infection, perinatal asphyxia, metabolic disorder

• Nonprogressive

• TYPES: Spastic– most common (65%); hypertonicity

Athetoid/dyskinetic – worm-like

Ataxic – wide based gait w/ repetitive movement

Mixed – spastic and athetoid

• S/sx: spasticity/rigidity, difficulty feeding, delayed speech and motor devt, mood swings, impulsive, short attention span, irritable

• Dx: Clinical

• Mx: antispastics, antibiotics, surgery, nutrition, prevention of injury, PT

NDx: Risk for injury r/t neuromuscular impairmentSelf care deficit r/t neuromuscular impairment

- ensure safety, assist in ADL, ensure adequate nutrition, assist children achieve maximum potential

Hydrocephalus• Impaired circulation and absorption of CSF

2 TYPES:

1. Obstructive/Noncommunicating – w/n ventricular system

2. Nonobstructive/Communicating – obliteration of SA cisterns or malfunction of arachnoid villi

S/sx: head enlargement, ant fontanel wide and bulging, scalp veins dilated, broad forehead, sclera bshows above iris, brisk tendon reflexes, spasticity, irritability, lethargy, poor appetite, cracked pot sound on percussion

Ndx:

Risk for ineffective cerebral tissue perfusion related to increased intracranial pressure

- monitor vs, head circumference, I and O

- O2

- position flat or head 30 deg

- do not lie on operative site

HYDROCEPHALUS

Risk for imbalanced nutrition, less than body requirements, related to increased intracranial pressure

- NPO until bowel sounds return

- position head w/o flexion

- observe for constipation

- note how child sucks

- IV fluids

- obtain daily weight

HYDROCEPHALUS

Spina Bifida• Collective term for all SC disorders

Spina Bifida Occulta – posterior laminae fail to fuse

- dimpling, abnormal tufts of hair

Meningocoele - meninges herniate through unformed vertebrae; protrusion covered by a layer of skin

- usually occurs in the lumbar region

- protrusion is covered by a skin layer or only the clear dura mater

SPINA BIFIDA

Myelomeningocoele – SC and meninges protrude through the vertebrae defect

- absent motor and sensory function

- flaccidity, lack of sensation in LE

- loss of bowel and bladder control

- may be accompanied by hydrocephalus

Dx: sonography

• Risk for infection r/t rupture or bacterial invasion of the neural tube sac

- position side lying or prone

- keep sac moist

- place under radiant warmer

- post op – prone until site is healed• Risk for ineffective cerebral tissue perfusion r/t

increased intracranial pressure

- measure head circumference

- assess for s/sx of inc ICP

SPINA BIFIDA

• Risk for impaired skin integrity r/t required prone positioning

- reposition head every 2 hrs if w/ hydrocephalus

- change diapers frequently• Impaired physical mobility r/t neural tube d/o

- passive exercises

- may use leg braces, crutches

- inspect lower extremities and buttocks for irritation or possible infection

• Risk for impaired elimination r/t neural tube d/o

- intermittent catheterization

- surgery

SPINA BIFIDA

Meningitis

• Inflammation of meninges

• Bacterial, Tuberculous, viral

S/sx: opisthotonus, neck rigidity, irritability, high pitched cry

Dx: Lumbar puncture, Bld C/S, Ct scan, MRI

NDx: Risk for infection r/t presence of infective organism

Tx: Abx

Hematologic Disorders

HEMATOLOGIC DISORDERS

Iron Deficiency Anemia

Infant’s iron supply 4-6 mos

Anemia – 9-24 mos

S/sx: pallor, tachycardia, irritability, Hg < 9 g/dl, susceptible to infection

Mgmt: iron fortified formula, iron rich diet and vitamins

Nsg care: give iron w/ vit c, use w/ dropper at the back of the mouth, expect black stools, provide iron rich food

Hemophilia A• Inherited interference w/ blood coagulation

• Factor VIII

• Sex linked recessive

• S/sx: excessive bleeding

NB – apparent

Pre-school – accidents/falls

School age – bleeding between joints

Adolescent – ulcers, hematuria

• Mx: factor VIII transfusion

NDx: Acute pain r/t bleeding into joints

Nursing Care

• Promote safety

• Watch out for bleeding – rest area, ice compress, elevate body part

• Monitor transfusion reaction

• Passive ROM

• Assist in gaining control of situation

Hemophilia B

• Christmas Factor• Clotting Factor IX

ACUTE LYMPHOCYTIC LEUKEMIA

• Uncontrolled proliferation of WBC

• Lymphoblast

• Most frequent CA in children

• 2-16 yo

• Males

S/sx: pallor, low grade fever, lethargy, petechiae, bleeding, vomiting, anorexia, bone pain, painless lymphadenopathy

Dx:WBC variable w/ blasts, low platelet and hematocrit, anemia

BMA > 25% blast cells

LEUKEMIA

BONE MARROW ASPIRATION

Mx: chemotherapy

Cx: CNS s/sx, renal failure

NDx: Risk for infection r/t decreased immune function

Activity intolerance r/t reduced oxygen carrying capacity of blood

LEUKEMIA

Nursing Care

• Prevent infection

• monitor bleeding and transfusion reactions

• Provide comfort and pain alleviation

• Health teaching

• Emotional and psychological support

Genitourinary Disorders

Urinary Tract Infection• Females• E coli• Ascending infection• S/Sx:infants – mimic GI d/o; dysuria, frequency,

hematuria, low grade fever, abdominal pain and bedwetting

• Dx: urine culture suprapubic any amount clean catch > 100,000/ml• Mx: antibiotic hydration

Acute Glomerulonephritis

• Inflammation of glomeruli or kidney

• Follows infection with strep10-14 days

• 5-10 yo• Males

S/sx:sudden onset of edema and hematuria, proteinuria, hypertension

Dx: urinalysis and 24 hour urine hypoalbuminemia inc ESR, BUN, Crea,

antistreptolysin O

Mx: semi fowlers diuretics, antibiotics

O2 antihypertensives

Nsg Care: quiet play activities diet – normal CHON, mod salt

restriction, fluid restriction daily weight and output

Nephrotic Syndrome

• Altered glomerular permeability(autoimmune); inc permeability to albumin

• 3 yo• Males• Minimal change syndrome • S/sx: proteinuria, edema-

periorbital area, hypoalbuminemia, hyperlipidemia

• Dx: urinalysis and 24 hr CHON, inc ESR

Mx:steroids, immunosupressant

NDx: Risk for decreased fluid volume r/t CHON and fluid loss

Imbalanced nutrition: less than BR r/t CHON and fluid loss

Nsg care: Adequate nutrition, proper diet – decrease saltWeigh daily, monitor I and OProtect edematous areasAdminister prescribed drugsHealth teaching

Wilm’s Tumor

• Malignant tumor of the kidney• Associated with other anomalies • 6 mos-5 yo, peaks 3-4 yo• Good prognosis• S/sx: abdominal mass, hematuria, low grade

fever, anemia, wt loss• Dx: CT scan• Mx: Nephrectomy, radiotherapy avoid abdominal palpation

Hypospadia/Epispadia

A. Hypospadia B. Epispadia

C. Hypospadia w/ chordee

Hypospadia - common - chordee - fibrous band

Mx: surgery

Nsg care: Post op – pain relief assist parents in coping

UROGENITAL DEFECTS

Cryptorchidism(Undescended Testis)• Failure of one or both testes to descend• Descend up to 6 weeks at birth• May be d/t dec testosterone

S/sx: right testis more common

Mx: chorionic gonadotrophin hormone

Orchiopexy 1 yo

Other Diseases

Sudden Infant Death Syndrome

• 1 mo-1 year old, peaks 2-4 mos • Full term/preterm• sudden and silent• the victim seems healthy• sleeping on prone position• Theories of causation: abnormalities in the brain

and metabolic disorder

Maternal risk factors - cigarette smoking during pregnancy, maternal age < 20 yo, poor prenatal care, low weight gain, anemia, use of illegal drugs and alcohol, low socioeconomic status

Newborn risk factors – cyanosis, tachycardia, respiratory distress, irritability, hypothermia, poor feeding

S I D S

S I D SNsg Dx:

Dysfunctional grieving r/t loss of a child

Management• assist psychologically - intense grief and

guilt for parents

Atopic Dermatitis

• 2 mos-3 yo• R/t food allergyS/sx: papular and vesicular skin

eruptions w/ erythema, pruritus, dry,flaky scales upon healing

Mx: reduce allergen, topical steroids

NDx: Impaired skin integrity r/t eczematous lesion

Nsg care: Reduce allergen Prevent skin dryness and

pruritus

Normal Skin

Smooth micro-reliefLow roughnessRegular desquamation

Dry SkinTortuous micro-reliefHigh roughnessIrregular desquamation

ATOPIC DERMATITIS

• NURSING MANAGEMENT

1. MEDS: ANTIHISTAMINES, ANTIPRURITICS, STEROIDAL CREAMS

2. Minimize the risk of infection

3. Promote skin integrity

4. Family Health teaching• Cotton fabrics, use mild detergents• Daily baths to hydrate the skin• Use topical moisturizers

Otitis Media

• Inflammation of the middle ear• 6-36 mos, 4-6 yo• S. Pneumoniae, H. Influenzae, M. Catarrhalis• Follows URTI

S/sx: pain in affected ear, fever

Cx: hearing impairment

Mx: antibiotics, analgesics, antipyretics

NDx: Acute pain r/t inflammatory process

- provide comfort, reinforce completion of antibiotic, offer liquids and finger food (prev pain when chewing)

Diarrhea

Viral – Rotavirus, AdenovirusBacterial – Shigella, Salmonella, CholeraProtozoan – Amoeba

TYPES:Mild: fever, irritable, 2-10 episodes/day, dry

mucous membranes, tachycardia - 2.5-5% wt lossMx: oral rehydration

Severe: fever, tachycardia, tachypnea, pale and cool skin, apprehensive/lethargic, obvious s/sx of dehydration, UO scanty, several episodes of loose stools

- 5-15% wt lossCx: dehydrationMx: fluid and electrolyte replacementDx: Stool exam and culture, Electrolyte determinationNDx: deficient fluid volume r/t fluid losses in stools

- promote hydration and comfort, Record I and O

DIARRHEA

Protein Energy Malnutrition

MarasmusLow calorie, low CHON

0-2 yo

(-) edema

“all skin and bone”

(+) growth retardation

Apathetic, quiet

Good appetite

Infrequent skin/hair changes

Anemia uncommon

KwashiorkorLow CHON

1-3 yo

(+) edema

Wasting variable

Growth retardation variable

Irritable, moaning

Poor appetite

(+) skin and hair changes

(+) anemia

PoisoningUsually 2-3 yo

Soap, cosmetics, detergents, drugs

Males>females – children

Females>males – adolescent

Mx:

1. Det age wt, type of poison swallowed, ime of ingestion, route of poisoning, amt ingested, present condition of child

2.Use syrup of ipecac to induce vomiting except:

caustic, corrosive, hydrocarbon, px is comatose

3. Activated charcoal then syrup of ipecac

4. Monitor VS

5. refer to hospital/poison control center

POISONING

POISONING

Acetylsalicilic acid (Aspirin)

S/sx: nausea, vomiting, fever, profuse sweating, flushing, hyperthermia, hyperventilation, convulsions, coma

Mx: stabilize airway and breathing

Fluid and electrolyte replacement

Activated charcoal

Alkalinization of urine

hemodialysis

Down’s Syndrome

Trisomy 21

Maternal age >35 yo, paternal age >55

Features: nose is broad and flat, eyelid have an extra fold of tissue at the inner canthus, palpebral fissure slants upwards, white specks in iris, tongue protrudes, back of the head is flat, neck is short, extra fat pad, low set ears, poor muscle tone, short thick fingers, simian crease, cognitively challenged

Poor immune function

Congenital heart diseases – Ventricular Septal Defect

Cataract

ALL occurs 20x more

Mx: early education and play opportunities

prevention of infection

counseling and support

DOWN’S SYNDROME

Child Abuse

• Non accidental injury inflicted by an adult

• Physical, emotional, sexual

• Children grow up to be abusers themselves and are violent

• Nsg Resp: treat injury, report to DSWD, NGO, Bantay Bata

SIGNS OF CHILD ABUSE

Substance Abuse

• Use of chemicals• Improve mental state• Induce euphoria• Peer pressure• Feel more confident• Adolescent rebellion

TYPES OF ABUSED SUBSTANCES

Tobacco - sign of maturity

Alcohol - most frequent - no stigma

Amphetamines – sense of well being, alertness, self esteem and wt loss

Anabolic steroids – improves athletic ability

Marijuana – stress reliever bec gives a sense of well being, altered sensory perception

TYPES OF ABUSED SUBSTANCES

Hallucinogens – distortions in vision, smell or hearing

Opiates – physiologic craving

Cocaine – inc VS, dec appetite, cardiovascular arrest, euphoria,

excitement, hallucinations

ASSESSMENT OF SUBSTANCE ABUSE

• Failure to complete homework• Poor reasoning ability• Decreased school attendance• Frequent mood swings• Deteriorating physical appearance• Recent change in peer group• Negative perception of parents

Nursing Intervention

• Caution against drug abuse• Provide counseling• refer to rehab facilities

Thank you!